MEDICARE: JENNY STRADER PT

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	14004	WI
2	225100000X	Physical Therapist	05009253A	IN

General Provider Information

NPI Number	:	1467659367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY STRADER PT

Provider Business Mailing Address
First Line	:	945 TALON CT
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-6646
Country	:	US
Telephone Number	:	260-615-3911
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 FAIRFIELD AVE STE 150
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-3450
Country	:	US
Telephone Number	:	260-744-5585
Fax Number	:	260-744-5586

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

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	05/03/2018

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Directions to “ JENNY STRADER PT” Practice Location

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