Provider Demographics
NPI:1861424202
Name:NOVAK, JEROME (PT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-3901
Mailing Address - Country:US
Mailing Address - Phone:262-880-1034
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2939
Practice Address - Country:US
Practice Address - Phone:262-880-1034
Practice Address - Fax:888-972-3708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-0135962251X0800X
WI9800-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic