Provider Demographics
NPI:1528087442
Name:DE WITT, JEANETTE MARIE (PT, ATC)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:MARIE
Last Name:DE WITT
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:MARIE
Other - Last Name:BRANDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, ATC
Mailing Address - Street 1:6233 BANKERS RD STE 12
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9700
Mailing Address - Country:US
Mailing Address - Phone:262-358-6730
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:6233 BANKERS RD STE 12
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-9700
Practice Address - Country:US
Practice Address - Phone:262-358-6730
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008334225100000X
WI11903-24225100000X
WI1315-392255A2300X
OH0010712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI859400073OtherMEDICARE
WI1528087442Medicaid
P01275365Medicare PIN
WI859400073OtherMEDICARE