Healthcare Provider Details

I. General information

NPI: 1255940714
Provider Name (Legal Business Name): JENNIFER LYNNE HORNBAKER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W MONROE ST
WYOCENA WI
53969-7168
US

IV. Provider business mailing address

50 S MEADOW LN
MADISON WI
53705-5002
US

V. Phone/Fax

Practice location:
  • Phone: 785-218-1648
  • Fax:
Mailing address:
  • Phone: 785-218-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15027-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: