Provider Demographics
NPI:1891170916
Name:KLUCK, JESSICA (PTA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:KLUCK
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 1:750 E LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 E LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9501
Practice Address - Country:US
Practice Address - Phone:705-886-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2208-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant