MEDICARE: DR. MACKENZIE JENSEN WHEELER 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

General Provider Information

NPI Number	:	1639760044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MACKENZIE JENSEN WHEELER DPT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10620 N PORT WASHINGTON RD STE 202
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5048
Country	:	US
Telephone Number	:	414-351-5794
Fax Number	:

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

Provider Enumeration Date	:	01/28/2021
Last Update Date	:	12/19/2023

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