Healthcare Provider Details

I. General information

NPI: 1831029305
Provider Name (Legal Business Name): JANINE MARIE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 N MILWAUKEE RIVER PKWY
GLENDALE WI
53209-3816
US

IV. Provider business mailing address

W164N9795 WATER ST
GERMANTOWN WI
53022-5032
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-7190
  • Fax:
Mailing address:
  • Phone: 262-227-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number592841
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: