Provider Demographics
NPI:1790048015
Name:NETTESHEIM, JENNIFER C (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:NETTESHEIM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:MANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:557 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2907
Mailing Address - Country:US
Mailing Address - Phone:608-754-6000
Mailing Address - Fax:608-755-7892
Practice Address - Street 1:557 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2907
Practice Address - Country:US
Practice Address - Phone:608-754-6000
Practice Address - Fax:608-755-7892
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11957-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790048015Medicaid
WIMANZJENOtherMERCYCARE INSURANCE
WIMANZJENOtherMERCYCARE INSURANCE
WI541760908Medicare PIN