Healthcare Provider Details

I. General information

NPI: 1457640963
Provider Name (Legal Business Name): JESSICA RYAN DAHMS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 22ND AVE
MONROE WI
53566-1569
US

IV. Provider business mailing address

60 N WESTWOOD AVE
FREEPORT IL
61032-3656
US

V. Phone/Fax

Practice location:
  • Phone: 608-324-1178
  • Fax:
Mailing address:
  • Phone: 815-275-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5009-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: