=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225551138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANN GEISBERGER PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2017
-----------------------------------------------------
Last Update Date | 07/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 CLEVELAND AVE
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53186-3876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-547-2123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N64W24266 IVY AVE
-----------------------------------------------------
City | SUSSEX
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53089-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1568-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------