Provider Demographics
NPI:1134335169
Name:SUESS, JILL SHEA (OTR)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SHEA
Last Name:SUESS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15985 W HEATHERLY DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5619
Mailing Address - Country:US
Mailing Address - Phone:262-641-0805
Mailing Address - Fax:
Practice Address - Street 1:402 FIRST STREET
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075
Practice Address - Country:US
Practice Address - Phone:920-994-9700
Practice Address - Fax:920-994-4606
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3789026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40902000Medicaid