Provider Demographics
NPI:1760633937
Name:JERDEE, KATIE FIONA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:FIONA
Last Name:JERDEE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-2622
Mailing Address - Country:US
Mailing Address - Phone:414-764-3628
Mailing Address - Fax:
Practice Address - Street 1:3205 WOOD RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5048
Practice Address - Country:US
Practice Address - Phone:126-259-8914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1921-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40892500OtherMEDICAID PROGRAM NON BILLING PROVIDER NUMBER