Provider Demographics
NPI:1053528083
Name:FRAZIER, JANE MARIE (PT)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:MARIE
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 CTY HWY PB
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508
Mailing Address - Country:US
Mailing Address - Phone:608-424-6221
Mailing Address - Fax:
Practice Address - Street 1:814 JACKSON ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1520
Practice Address - Country:US
Practice Address - Phone:608-873-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1674-024174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40133200Medicaid