Provider Demographics
NPI:1710626486
Name:SMITH, JESSICA ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:AHRENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:471 S ARCH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1832
Mailing Address - Country:US
Mailing Address - Phone:715-246-3809
Mailing Address - Fax:
Practice Address - Street 1:471 S ARCH AVE
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1832
Practice Address - Country:US
Practice Address - Phone:715-246-3809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15795-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist