Provider Demographics
NPI:1689188435
Name:WEISENBECK, JODI ANN PAWLIK (PTA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN PAWLIK
Last Name:WEISENBECK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:ANN
Other - Last Name:PAWLIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W2029 COUNTY ROAD K
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:WI
Mailing Address - Zip Code:54736-8040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 BRIDGE CREEK LN
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:WI
Practice Address - Zip Code:54722-2603
Practice Address - Country:US
Practice Address - Phone:715-286-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2680-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty