Healthcare Provider Details

I. General information

NPI: 1194316455
Provider Name (Legal Business Name): JAMESON MATTHEW OTTE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

IV. Provider business mailing address

2629 N 7TH ST
SHEBOYGAN WI
53083-4932
US

V. Phone/Fax

Practice location:
  • Phone: 920-451-5559
  • Fax: 920-451-5121
Mailing address:
  • Phone: 920-451-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number14657-24
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number14657-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: