Healthcare Provider Details

I. General information

NPI: 1225714520
Provider Name (Legal Business Name): JENNIFER KEUPPER ONEIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N PAGE ST
STOUGHTON WI
53589-1309
US

IV. Provider business mailing address

1792 WILLIAMS DR
STOUGHTON WI
53589-3342
US

V. Phone/Fax

Practice location:
  • Phone: 734-674-5823
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15076-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: