Provider Demographics
NPI:1679860845
Name:HAMM, JACQUELINE NAOMI (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NAOMI
Last Name:HAMM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NAOMI
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:N12545 CTY RD G
Mailing Address - Street 2:
Mailing Address - City:NECEDAH
Mailing Address - State:WI
Mailing Address - Zip Code:54646
Mailing Address - Country:US
Mailing Address - Phone:608-565-7708
Mailing Address - Fax:
Practice Address - Street 1:106 S HOLMEN DR
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-9467
Practice Address - Country:US
Practice Address - Phone:608-526-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1756-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant