Provider Demographics
NPI:1902363823
Name:KEGLER, JENNA (PTA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:KEGLER
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 1:200 S. NINTH STREET
Mailing Address - Street 2:
Mailing Address - City:DEPERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115
Mailing Address - Country:US
Mailing Address - Phone:920-336-5680
Mailing Address - Fax:920-336-5882
Practice Address - Street 1:200 S. NINTH STREET
Practice Address - Street 2:
Practice Address - City:DEPERE
Practice Address - State:WI
Practice Address - Zip Code:54115
Practice Address - Country:US
Practice Address - Phone:920-336-5680
Practice Address - Fax:920-336-5882
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2821-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant