Provider Demographics
NPI:1649476789
Name:ICKSTADT, JOANNE KAREN (PT)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:KAREN
Last Name:ICKSTADT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 3 CRABS RD
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7852
Mailing Address - Country:US
Mailing Address - Phone:719-510-6420
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE
Practice Address - Street 2:SUITE #200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7085
Practice Address - Country:US
Practice Address - Phone:800-634-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist