MEDICARE: PATRICIA JACOBY JOHNSON P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4556 - 024	WI

General Provider Information

NPI Number	:	1205971736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA JACOBY JOHNSON P.T.

Provider Business Mailing Address
First Line	:	3844 OAK RIDGE CT
Second Line	:
City	:	COLGATE
State	:	WI
Zip	:	53017-9361
Country	:	US
Telephone Number	:	262-628-1975
Fax Number	:

Provider Business Practice Location Address
First Line	:	N88W16598 MAIN ST
Second Line	:
City	:	MENOMONEE FALLS
State	:	WI
Zip	:	53051-2845
Country	:	US
Telephone Number	:	262-502-0028
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	10/16/2007

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