Provider Demographics
NPI:1821344391
Name:SKREDE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SKREDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1013
Mailing Address - Country:US
Mailing Address - Phone:608-606-3144
Mailing Address - Fax:
Practice Address - Street 1:508 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1013
Practice Address - Country:US
Practice Address - Phone:608-606-3144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1905-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant