Provider Demographics
NPI:1710146998
Name:MARQUARDT, JODI ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:ANN
Last Name:MARQUARDT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JODI
Other - Middle Name:ANN
Other - Last Name:HUBERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:139 W RAILROAD ST
Mailing Address - Street 2:PO BOX 321
Mailing Address - City:LENA
Mailing Address - State:WI
Mailing Address - Zip Code:54139-0321
Mailing Address - Country:US
Mailing Address - Phone:920-829-5018
Mailing Address - Fax:
Practice Address - Street 1:139 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:WI
Practice Address - Zip Code:54139-0321
Practice Address - Country:US
Practice Address - Phone:920-829-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI948-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant