Provider Demographics
NPI:1770797326
Name:KIZEWSKI, JANA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JANA
Middle Name:MARIE
Last Name:KIZEWSKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 MULBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-7756
Mailing Address - Country:US
Mailing Address - Phone:715-421-2727
Mailing Address - Fax:
Practice Address - Street 1:717 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:WEYAUWEGA
Practice Address - State:WI
Practice Address - Zip Code:54983-9024
Practice Address - Country:US
Practice Address - Phone:920-867-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI578019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40398900Medicaid