Provider Demographics
NPI:1124687017
Name:JIRACEK, ANGELA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:JIRACEK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W76N677 WAUWATOSA RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-1799
Mailing Address - Country:US
Mailing Address - Phone:262-377-5060
Mailing Address - Fax:
Practice Address - Street 1:W76N677 WAUWATOSA RD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1707
Practice Address - Country:US
Practice Address - Phone:262-377-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8232251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic