Healthcare Provider Details

I. General information

NPI: 1265346233
Provider Name (Legal Business Name): JARED DIECKMAN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 30TH AVE
ELK MOUND WI
54739-4213
US

IV. Provider business mailing address

3171 30TH AVE
ELK MOUND WI
54739-4213
US

V. Phone/Fax

Practice location:
  • Phone: 715-415-4876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1792824
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: