Healthcare Provider Details

I. General information

NPI: 1316754641
Provider Name (Legal Business Name): JOCELYN KOERNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CLARK ST
LODI WI
53555-1010
US

IV. Provider business mailing address

W7380 COUNTY ROAD B
POYNETTE WI
53955-8833
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-3241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number719827
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: