Healthcare Provider Details

I. General information

NPI: 1205264843
Provider Name (Legal Business Name): JENNIFER MAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SCHABOW ST
GRESHAM WI
54128-9505
US

IV. Provider business mailing address

223 W PARK ST
GILLETT WI
54124-9414
US

V. Phone/Fax

Practice location:
  • Phone: 715-787-3211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6143-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: