Provider Demographics
NPI:1841888500
Name:KVALHEIM, JENNIFER SUE (COTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUE
Last Name:KVALHEIM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 DONNA ST
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1500
Mailing Address - Country:US
Mailing Address - Phone:920-979-1933
Mailing Address - Fax:
Practice Address - Street 1:115 E ARNDT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2461
Practice Address - Country:US
Practice Address - Phone:920-923-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224Z00000X
WI5262224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant