=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598156598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA DIERINGER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2015
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 N PORT WASHINGTON RD
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217-3998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-966-2132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 252 TIMBLIN DR APT 7
-----------------------------------------------------
City | KEWASKUM
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53040-9174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-980-4870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5612-26
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------