Provider Demographics
NPI:1679193494
Name:NOEL, JADE (PTA)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:NOEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JADE
Other - Last Name:JABLONSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2328 W KENDALL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4321
Mailing Address - Country:US
Mailing Address - Phone:262-442-9597
Mailing Address - Fax:
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2277-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant