Provider Demographics
NPI:1972969723
Name:ELSEN, JEROLD
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:
Last Name:ELSEN
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 1:921 SCRIBNER ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1322
Practice Address - Country:US
Practice Address - Phone:712-635-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-10
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5072-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist