Provider Demographics
NPI:1992013106
Name:BALLWEG, JENNIFER L (DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BALLWEG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1864
Mailing Address - Country:US
Mailing Address - Phone:608-873-2292
Mailing Address - Fax:
Practice Address - Street 1:2300 US HWY 51 138
Practice Address - Street 2:SUITE G
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-0000
Practice Address - Country:US
Practice Address - Phone:608-873-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11544-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11544-024Medicaid