Provider Demographics
NPI:1528104429
Name:KITELINGER, JENNIFER LYNN (OTR)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:KITELINGER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 REAUME AVE
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2430
Mailing Address - Country:US
Mailing Address - Phone:920-205-5727
Mailing Address - Fax:920-759-1937
Practice Address - Street 1:311 REAUME AVE
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2430
Practice Address - Country:US
Practice Address - Phone:920-205-5727
Practice Address - Fax:920-759-1937
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4780-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4780-026OtherSTATE LICENSES
WI40901500Medicaid