Provider Demographics
NPI:1942562152
Name:ALIZADEH, JENNIFER B (PT)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:B
Last Name:ALIZADEH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:645 ELM GROVE RD
Mailing Address - Street 2:APT 4
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2545
Mailing Address - Country:US
Mailing Address - Phone:262-492-9080
Mailing Address - Fax:
Practice Address - Street 1:597 KINGSWOOD AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6399
Practice Address - Country:US
Practice Address - Phone:920-238-3032
Practice Address - Fax:920-238-3048
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WI12075-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400096267Medicare PIN