Provider Demographics
NPI:1780806992
Name:ADEBOGUN, JEAN LOUISE (COTA)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:LOUISE
Last Name:ADEBOGUN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10532 N ELDERBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4494
Mailing Address - Country:US
Mailing Address - Phone:262-512-0499
Mailing Address - Fax:
Practice Address - Street 1:N27W5707 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2852
Practice Address - Country:US
Practice Address - Phone:262-376-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40723200Medicaid