Provider Demographics
NPI:1962624700
Name:STAPLEMAN, JILLIAN ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:ANN
Last Name:STAPLEMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JILLIAN
Other - Middle Name:ANN
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:509 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-3448
Mailing Address - Country:US
Mailing Address - Phone:262-770-8355
Mailing Address - Fax:
Practice Address - Street 1:8633 32ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-5187
Practice Address - Country:US
Practice Address - Phone:262-694-8300
Practice Address - Fax:262-694-3622
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI680-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40403800Medicaid