Healthcare Provider Details

I. General information

NPI: 1356641633
Provider Name (Legal Business Name): JARED STORY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9047 W GREENFIELD AVE
WEST ALLIS WI
53214-2808
US

IV. Provider business mailing address

9047 W GREENFIELD AVE
WEST ALLIS WI
53214-2808
US

V. Phone/Fax

Practice location:
  • Phone: 414-453-9290
  • Fax: 414-607-0924
Mailing address:
  • Phone: 414-453-9290
  • Fax: 414-607-0924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1679-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: