Provider Demographics
NPI:1720277999
Name:HAAG, JESSICA JADE MARIE (ATC, LAT)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:JADE MARIE
Last Name:HAAG
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 MCCARTHY RD
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:WI
Mailing Address - Zip Code:54139-9534
Mailing Address - Country:US
Mailing Address - Phone:920-737-5685
Mailing Address - Fax:
Practice Address - Street 1:5240 MCCARTHY RD
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:WI
Practice Address - Zip Code:54139-9534
Practice Address - Country:US
Practice Address - Phone:920-737-5685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI583-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer