Provider Demographics
NPI:1699820761
Name:BRICCO, JILLENE A (OTR)
Entity type:Individual
Prefix:
First Name:JILLENE
Middle Name:A
Last Name:BRICCO
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:N3131 REILAND RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7802
Mailing Address - Country:US
Mailing Address - Phone:920-730-6345
Mailing Address - Fax:
Practice Address - Street 1:3305 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9001
Practice Address - Country:US
Practice Address - Phone:920-735-9234
Practice Address - Fax:920-739-8288
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40566700Medicaid