Provider Demographics
NPI:1710094115
Name:GADDES, JENNIFER CS (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CS
Last Name:GADDES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:SCHAUFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:
Practice Address - Street 1:10560 APPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SISTER BAY
Practice Address - State:WI
Practice Address - Zip Code:54234-9005
Practice Address - Country:US
Practice Address - Phone:920-854-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6376225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40324600Medicaid
WI521358Medicare Oscar/Certification