Provider Demographics
NPI:1942994256
Name:HEINRICH, JACK (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HEINRICH
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10930 W POTTER RD STE C
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3450
Mailing Address - Country:US
Mailing Address - Phone:414-400-6556
Mailing Address - Fax:414-400-6557
Practice Address - Street 1:10930 W POTTER RD STE C
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3450
Practice Address - Country:US
Practice Address - Phone:414-400-6556
Practice Address - Fax:414-400-6557
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16297-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist