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General NPI Number Information
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NPI Number | 1982878948
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Entity Type | Individual
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Provider Name | JEFFREY BRIAN MAHAN P.T.
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Gender | Male
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Dates
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Enumeration Date | 04/21/2008
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Last Update Date | 04/21/2008
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Provider Practice Location Address
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Address Line | 121 HOSPITAL DR
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City | WATERTOWN
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State | WI
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Zip | 53098-3303
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Country | US
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Telephone | 920-392-1102
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Fax | 479-201-0257
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Provider Business Mailing Address
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Address Line | 440 WELLS ST STE 200
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City | DELAFIELD
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State | WI
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Zip | 53018-1412
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Country | US
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Telephone | 920-392-1102
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Fax | 479-201-0257
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 4686-024
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License Number State | WI
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