Provider Demographics
NPI:1134373830
Name:SEEGER, JACLYN ANN (COTA)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ANN
Last Name:SEEGER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6765 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54962-9775
Mailing Address - Country:US
Mailing Address - Phone:920-244-7537
Mailing Address - Fax:
Practice Address - Street 1:70 W GREEN TREE RD
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1009
Practice Address - Country:US
Practice Address - Phone:715-823-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1976-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41040500Medicaid