Provider Demographics
NPI:1982878948
Name:MAHAN, JEFFREY BRIAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:BRIAN
Last Name:MAHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WELLS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1412
Mailing Address - Country:US
Mailing Address - Phone:920-392-1102
Mailing Address - Fax:479-201-0257
Practice Address - Street 1:121 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-392-1102
Practice Address - Fax:479-201-0257
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4686-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist