Provider Demographics
NPI:1346724168
Name:KLOS, JENNA SUE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:SUE
Last Name:KLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:SUE
Other - Last Name:HERMSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:137 ACORN LN
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-9269
Mailing Address - Country:US
Mailing Address - Phone:563-608-5510
Mailing Address - Fax:
Practice Address - Street 1:137 ACORN LN
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9269
Practice Address - Country:US
Practice Address - Phone:563-608-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106364225X00000X
WI6815-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist