Provider Demographics
NPI:1750630471
Name:JECEVICUS, KRYSTAL K (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:K
Last Name:JECEVICUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:KRYSTAL
Other - Middle Name:K
Other - Last Name:COUNTERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3415 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1924
Mailing Address - Country:US
Mailing Address - Phone:262-653-2940
Mailing Address - Fax:262-657-6681
Practice Address - Street 1:3415 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1924
Practice Address - Country:US
Practice Address - Phone:262-653-2940
Practice Address - Fax:262-657-6681
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1549-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant