Provider Demographics
NPI:1902102643
Name:HOUGAN, JODI CAROL (PTA)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:CAROL
Last Name:HOUGAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 N SPRING ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1283
Mailing Address - Country:US
Mailing Address - Phone:920-356-0122
Mailing Address - Fax:920-356-0470
Practice Address - Street 1:1626 N SPRING ST
Practice Address - Street 2:SUITE B
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1283
Practice Address - Country:US
Practice Address - Phone:920-356-0122
Practice Address - Fax:920-356-0470
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1597-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant