Provider Demographics
NPI:1750565487
Name:SHIMON, JENNIFER BROOKE (OTR)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:SHIMON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 AUDUBON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2219
Mailing Address - Country:US
Mailing Address - Phone:262-375-0931
Mailing Address - Fax:
Practice Address - Street 1:1119 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1209
Practice Address - Country:US
Practice Address - Phone:262-284-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3537026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist