Provider Demographics
NPI:1841567765
Name:JAKE, BRITTANY WANDA (PTA)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:WANDA
Last Name:JAKE
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 1:412 OAKHURST AVE
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1610
Mailing Address - Country:US
Mailing Address - Phone:622-945-9426
Mailing Address - Fax:
Practice Address - Street 1:10330 PRAIRIE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1947
Practice Address - Country:US
Practice Address - Phone:262-612-2829
Practice Address - Fax:262-634-3358
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1781-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant