Basic Information
| Provider Information | |||||||||
| NPI: | 1073028320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEUWENHUIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | E | ||||||||
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| OtherLastName: | AULT | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 122 E COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549115794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209963264 | ||||||||
| FaxNumber: | 9208305970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207314101 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 225X00000X | 5513 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.