Healthcare Provider Details

I. General information

NPI: 1982974606
Provider Name (Legal Business Name): JENNIFER MARY WOS LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 N BROADWAY
MILWAUKEE WI
53202-3109
US

IV. Provider business mailing address

405 SOUTHTOWNE DR #K208
SOUTH MILWAUKEE WI
53172-4280
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-2588
  • Fax: 414-277-2495
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1207-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: