MEDICARE: MRS. JEANETTE MARIE DE WITT PT, ATC

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	008334	OH
2	225100000X	Physical Therapist	11903-24	WI
3	2255A2300X	Athletic Trainer	1315-39	WI
4	2255A2300X	Athletic Trainer	001071	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	859400073	OTHER	WI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528087442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANETTE MARIE DE WITT PT, ATC

Provider Business Mailing Address
First Line	:	6233 BANKERS RD STE 12
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-358-6730
Fax Number	:	866-245-8064

Provider Business Practice Location Address
First Line	:	6233 BANKERS RD STE 12
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-358-6730
Fax Number	:	866-245-8064

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	03/01/2017

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