Healthcare Provider Details

I. General information

NPI: 1720333594
Provider Name (Legal Business Name): ANNETTE C JEPPERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 SOUTH MONROE ST
LANCASTER WI
53813-2054
US

IV. Provider business mailing address

507 SOUTH MONROE STREET, GRANT REGIONAL HEALTH CENTER
LANCASTER WI
53813-9306
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-2113
  • Fax:
Mailing address:
  • Phone: 608-723-2113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number119-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: