Healthcare Provider Details

I. General information

NPI: 1508904376
Provider Name (Legal Business Name): JENNIFER KAY GUNDERSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 WEST MEQUON RD
MEQUON WI
53092
US

IV. Provider business mailing address

W64N332 MADISON AVE
CEDARBURG WI
53012-2331
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-8030
  • Fax: 262-241-8304
Mailing address:
  • Phone: 608-469-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number10563-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: