Active NPI
Jill Wallace, PT
- Physical Therapist
- Waukesha, WI
National Provider Identifier
1104883099
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 10232
- Practice address
- W239N1812 Rockwood Dr Ste 100
Phcma Inc.
Waukesha, WI 53188-1113 - Phone
- (262) 523-0310
- NPI assigned
- Apr 26, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 10232 | WI | Primary |
Addresses
Primary practice location
W239N1812 Rockwood Dr Ste 100
Phcma Inc.
Waukesha, WI 53188-1113
Mailing address
W239N1812 Rockwood Dr Ste 100
Phcma Inc.
Waukesha, WI 53188-1113
Phone (262) 523-0310
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 40432300 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10232 | WI | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medical Associates Health Centers-Occupational Health | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
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- Menomonee Falls, WI
- NPI 1205910585
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146009600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1326844800000",
"number": "1104883099",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "W239N1812 ROCKWOOD DR STE 100",
"address_2": "PHCMA INC.",
"city": "WAUKESHA",
"state": "WI",
"postal_code": "531881113",
"telephone_number": "262-523-0310"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "W239N1812 ROCKWOOD DR STE 100",
"address_2": "PHCMA INC.",
"city": "WAUKESHA",
"state": "WI",
"postal_code": "531881113",
"telephone_number": "262-523-0310"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JILL",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-04-26",
"last_updated": "2012-01-18",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "WI",
"license": "10232",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "40432300",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Waukesha, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 18, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.