Provider Demographics
NPI:1780625764
Name:GRACE-JENSEN, MICHELLE M (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:GRACE-JENSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:W8093 COUNTY A
Mailing Address - Street 2:
Mailing Address - City:ADELL
Mailing Address - State:WI
Mailing Address - Zip Code:53001-1462
Mailing Address - Country:US
Mailing Address - Phone:920-994-2599
Mailing Address - Fax:
Practice Address - Street 1:233 CARROLL ST
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1795
Practice Address - Country:US
Practice Address - Phone:920-912-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3728-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36117700Medicaid