Provider Demographics
NPI:1801363403
Name:MERRITT, JENNIFER A (LAT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MERRITT
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W145N10170 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-5329
Mailing Address - Country:US
Mailing Address - Phone:262-490-9466
Mailing Address - Fax:
Practice Address - Street 1:1245 N BROADWAY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2507
Practice Address - Country:US
Practice Address - Phone:262-490-9466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer