Provider Demographics
NPI:1790423390
Name:JELACIC, MADELINE RAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:RAE
Last Name:JELACIC
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BERKLEY PKWY APT 128
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64120-1412
Mailing Address - Country:US
Mailing Address - Phone:262-844-3305
Mailing Address - Fax:
Practice Address - Street 1:17055 FRANCES ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-4655
Practice Address - Country:US
Practice Address - Phone:402-280-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist