Provider Demographics
NPI:1801912423
Name:BLAHA, JILL (MPT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BLAHA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 WINDSONG WAY
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115
Mailing Address - Country:US
Mailing Address - Phone:920-983-6502
Mailing Address - Fax:
Practice Address - Street 1:1142 ORLANDO DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9484
Practice Address - Country:US
Practice Address - Phone:920-339-0700
Practice Address - Fax:920-330-0278
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6518-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40331800Medicaid