Healthcare Provider Details

I. General information

NPI: 1336663756
Provider Name (Legal Business Name): JENNA R MIELKE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA R PITT

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 E VERONA AVE
VERONA WI
53593-1227
US

IV. Provider business mailing address

416 E VERONA AVE
VERONA WI
53593-1227
US

V. Phone/Fax

Practice location:
  • Phone: 608-848-6628
  • Fax: 608-848-6629
Mailing address:
  • Phone: 608-848-6628
  • Fax: 608-848-6629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13930-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: