Healthcare Provider Details

I. General information

NPI: 1083836092
Provider Name (Legal Business Name): JAMIE L BOCKHOP PT/LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 14TH STREET SUITE 2
BARABOO WI
53913
US

IV. Provider business mailing address

PO BOX 31
BARABOO WI
53913
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-2334
  • Fax: 608-356-2636
Mailing address:
  • Phone: 608-356-2334
  • Fax: 608-356-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10782-024
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10782-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: