Provider Demographics
NPI:1861508798
Name:DROKE, JENNIFER (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DROKE
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:BOX 78534
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278
Mailing Address - Country:US
Mailing Address - Phone:815-381-7431
Mailing Address - Fax:815-381-7498
Practice Address - Street 1:324 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-5090
Practice Address - Country:US
Practice Address - Phone:815-381-7431
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160-004002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant