Healthcare Provider Details

I. General information

NPI: 1356518062
Provider Name (Legal Business Name): JILL M WURM PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 BLACK RIVER AVE
WESTBY WI
54667-1127
US

IV. Provider business mailing address

4116 RIVERVIEW DR
LA CROSSE WI
54601-2267
US

V. Phone/Fax

Practice location:
  • Phone: 608-634-3747
  • Fax:
Mailing address:
  • Phone: 608-787-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number737-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: