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General NPI Number Information
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NPI Number | 1790975423
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Entity Type | Individual
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Provider Name | JILL MARGARET EGBERT PTA
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Gender | Female
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Dates
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Enumeration Date | 07/30/2007
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 225 MEMORIAL DR
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City | BERLIN
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State | WI
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Zip | 54923-1243
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Country | US
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Telephone | 920-361-5534
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 26
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City | GREEN LAKE
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State | WI
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Zip | 54941-0026
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Country | US
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Telephone | 920-294-0189
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 137-019
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License Number State | WI
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