Provider Demographics
NPI:1649209313
Name:JEANETTA, JOSEPH FRANK
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:FRANK
Last Name:JEANETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5335
Mailing Address - Country:US
Mailing Address - Phone:715-395-5400
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-395-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP49757OtherHEALTHPARTNERS
WI40089100Medicaid