Provider Demographics
NPI:1518214576
Name:MERCHAK, JESSICA (PT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MERCHAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:KOTAREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2801 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2878
Mailing Address - Country:US
Mailing Address - Phone:920-337-1122
Mailing Address - Fax:920-337-9811
Practice Address - Street 1:2801 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2878
Practice Address - Country:US
Practice Address - Phone:920-337-1122
Practice Address - Fax:920-337-9811
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11956-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist