Basic Information
| Provider Information | |||||||||
| NPI: | 1326556507 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAHRENKRUG | ||||||||
| FirstName: | JAMIE | ||||||||
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| OtherLastName: | ROHM | ||||||||
| OtherFirstName: | JAMIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 207 JADEN DR | ||||||||
| Address2: | |||||||||
| City: | MILLTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548589075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154975903 | ||||||||
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| Practice Location | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2018 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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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 | 2255A2300X | 1610-39 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.