Provider Demographics
NPI:1740772961
Name:RONNEBAUM, JESSICA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:RONNEBAUM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:PESCHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:819 OREGON ST
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:KS
Mailing Address - Zip Code:66434-2205
Mailing Address - Country:US
Mailing Address - Phone:402-852-2231
Mailing Address - Fax:
Practice Address - Street 1:600 I ST
Practice Address - Street 2:
Practice Address - City:PAWNEE CITY
Practice Address - State:NE
Practice Address - Zip Code:68420-3001
Practice Address - Country:US
Practice Address - Phone:402-852-2231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist