Provider Demographics
NPI:1659758704
Name:BERANEK, JACOLYN (DPT)
Entity Type:Individual
Prefix:MS
First Name:JACOLYN
Middle Name:
Last Name:BERANEK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 SOUTH 102ND STREET, SUITE 340
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2141
Mailing Address - Country:US
Mailing Address - Phone:414-329-2500
Mailing Address - Fax:414-329-2501
Practice Address - Street 1:2448 SOUTH 102ND STREET, SUITE 340
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2141
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:414-329-2501
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist