Provider Demographics
NPI:1811359458
Name:LAUE, JENNIE (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:LAUE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-1254
Mailing Address - Country:US
Mailing Address - Phone:719-258-0072
Mailing Address - Fax:
Practice Address - Street 1:559 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-1254
Practice Address - Country:US
Practice Address - Phone:719-258-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA0000500313M00000X
WI5767-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility