Healthcare Provider Details

I. General information

NPI: 1033322847
Provider Name (Legal Business Name): JANE EVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE CHERTI

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COLLINS RD
JEFFERSON WI
53549-2939
US

IV. Provider business mailing address

N4864 N HELENVILLE RD
HELENVILLE WI
53137-9797
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-6077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number578-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: