Provider Demographics
NPI:1932246246
Name:CROSS, JEREMY D (MSPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:CROSS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-433-7995
Practice Address - Fax:920-433-3458
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10958-024225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36159200Medicaid
NYP3663022OtherOXFORD HEALTHCARE
NY027593-1OtherLICENSCE NUMBER
NY027593-1OtherLICENSCE NUMBER
NYQ31Q31Medicare ID - Type Unspecified
WI002086030Medicare PIN
NYP3663022OtherOXFORD HEALTHCARE
WI002186519Medicare PIN