Provider Demographics
NPI:1659547115
Name:WIRTH, JAN MARIE (BC-HIS)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:MARIE
Last Name:WIRTH
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:MARIE
Other - Last Name:FRANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BC-HIS
Mailing Address - Street 1:2525 WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-682-4990
Mailing Address - Fax:
Practice Address - Street 1:2525 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-682-4990
Practice Address - Fax:920-769-5131
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1169-060237700000X
WI1169237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42834600Medicaid