Provider Demographics
NPI:1851872907
Name:JEGEN, STEPHANIE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JEGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7250 S 46TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8795
Mailing Address - Country:US
Mailing Address - Phone:414-531-4846
Mailing Address - Fax:
Practice Address - Street 1:S77W12929 MCSHANE DR
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-4052
Practice Address - Country:US
Practice Address - Phone:414-529-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1466-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant