Provider Demographics
NPI:1841524451
Name:EGGEBRECHT, JONATHAN (OTR)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EGGEBRECHT
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 W BAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3404
Mailing Address - Country:US
Mailing Address - Phone:414-331-2045
Mailing Address - Fax:
Practice Address - Street 1:3540 S 43RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-1502
Practice Address - Country:US
Practice Address - Phone:414-541-1000
Practice Address - Fax:414-328-2159
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4746026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist