Provider Demographics
NPI:1619310620
Name:JALLING, DEBORAH (LAT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:JALLING
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 OSHKOSH ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-1635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1370 N SHAWANO ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-7944
Practice Address - Country:US
Practice Address - Phone:920-982-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1129-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer