Provider Demographics
NPI:1720118391
Name:JAGLINSKI, KEITH M (PTA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:M
Last Name:JAGLINSKI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871
Mailing Address - Country:US
Mailing Address - Phone:715-468-7833
Mailing Address - Fax:715-468-7839
Practice Address - Street 1:113 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-7833
Practice Address - Fax:715-468-7839
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI118209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40477900Medicaid