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General NPI Number Information
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NPI Number | 1598954844
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Entity Type | Individual
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Provider Name | JESSI REA ATC
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Gender | Female
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Dates
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Enumeration Date | 10/22/2007
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Last Update Date | 01/15/2015
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Provider Practice Location Address
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Address Line | 2835 N GRANDVIEW BLVD
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City | PEWAUKEE
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State | WI
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Zip | 53072-5546
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Country | US
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Telephone | 262-574-1100
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Fax | 262-574-5193
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Provider Business Mailing Address
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Address Line | 103 N 75TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53213-3515
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Country | US
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Telephone | 262-227-3473
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 662-39
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License Number State | WI
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