Provider Demographics
NPI:1194032383
Name:RADKE, JENNIFER (COTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RADKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MARY ST
Mailing Address - Street 2:APT. 103
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1080
Mailing Address - Country:US
Mailing Address - Phone:715-218-2113
Mailing Address - Fax:
Practice Address - Street 1:210 MARY ST
Practice Address - Street 2:APT. 103
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1080
Practice Address - Country:US
Practice Address - Phone:715-218-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4768224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant