Provider Demographics
NPI:1063547149
Name:VETTER, JACQUELINE M (PT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:VETTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3616
Mailing Address - Country:US
Mailing Address - Phone:414-442-2429
Mailing Address - Fax:
Practice Address - Street 1:4448 W LOOMIS RD
Practice Address - Street 2:STE 205
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4800
Practice Address - Country:US
Practice Address - Phone:414-281-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP89897Medicare UPIN