Provider Demographics
NPI:1699968016
Name:BROGELMAN, JAY TIMOTHY
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:TIMOTHY
Last Name:BROGELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 CLIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-9224
Mailing Address - Country:US
Mailing Address - Phone:715-828-0904
Mailing Address - Fax:
Practice Address - Street 1:N27 W5707 LINCOLN BLVD.
Practice Address - Street 2:CEDAR SPRINGS HEALTH AND REHABILITATION CENTER
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-376-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2047-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41049200Medicaid