MEDICARE: DR. JACQUELINE NDIENTIEN NCHINDA-PUNGONG BSC-PT, MSC, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5651	WI

General Provider Information

NPI Number	:	1316153000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE NDIENTIEN NCHINDA-PUNGONG BSC-PT, MSC, DPT

Provider Business Mailing Address
First Line	:	10137 S WINDSOR DR
Second Line	:
City	:	OAK CREEK
State	:	WI
Zip	:	53154-5580
Country	:	US
Telephone Number	:	414-762-8514
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 S CHICAGO AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-3708
Country	:	US
Telephone Number	:	414-764-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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