Provider Demographics
NPI:1194278473
Name:HOLT, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HOLT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:833 S 114TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-2225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12870-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist