Healthcare Provider Details

I. General information

NPI: 1710146998
Provider Name (Legal Business Name): JODI ANN MARQUARDT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI ANN HUBERTY PTA

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 W RAILROAD ST
LENA WI
54139-0321
US

IV. Provider business mailing address

139 W RAILROAD ST PO BOX 321
LENA WI
54139-0321
US

V. Phone/Fax

Practice location:
  • Phone: 920-829-5018
  • Fax:
Mailing address:
  • Phone: 920-829-5018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number948-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: