Provider Demographics
NPI:1144639683
Name:SCHLICHT, JENNA M (DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:SCHLICHT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:BRUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:3503 E. LAYTON AVE
Practice Address - Street 2:STE 100
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1408
Practice Address - Country:US
Practice Address - Phone:414-489-0270
Practice Address - Fax:414-489-0356
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12795-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12734215OtherCAQH
WI100040276Medicaid