Provider Demographics
NPI:1962795021
Name:SOUTHARD, JACQUELINE C (DPT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FLIESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-246-6800
Mailing Address - Fax:414-246-6405
Practice Address - Street 1:9000 W SURA LN
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3477
Practice Address - Country:US
Practice Address - Phone:414-246-6800
Practice Address - Fax:414-246-6405
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WI11733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962795021Medicaid
WIK400183172Medicare PIN
WI832070043Medicare PIN