Basic Information
| Provider Information | |||||||||
| NPI: | 1043457419 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HAAG | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3602 W SOUTHWOOD DR | ||||||||
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| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531329140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145597842 | ||||||||
| FaxNumber: | 8664262811 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 BEVILLE RD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | SOUTH DAYTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321191712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867564395 | ||||||||
| FaxNumber: | 8664262811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 01/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11083-024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.