Healthcare Provider Details

I. General information

NPI: 1588657902
Provider Name (Legal Business Name): JEFFREY P SISCHO DPT, LAT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N EAST AVE PT BUILDING, #116
WAUKESHA WI
53186-3103
US

IV. Provider business mailing address

3121 E DIANE DR
OAK CREEK WI
53154-3483
US

V. Phone/Fax

Practice location:
  • Phone: 262-951-3049
  • Fax:
Mailing address:
  • Phone: 414-570-1450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number137-039
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10699-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: