Provider Demographics
NPI:1063588341
Name:RAETHER, JON C (DC)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:C
Last Name:RAETHER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ALTONA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-9542
Mailing Address - Country:US
Mailing Address - Phone:920-898-4225
Mailing Address - Fax:920-898-4597
Practice Address - Street 1:2625 ALTONA AVE
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-9542
Practice Address - Country:US
Practice Address - Phone:920-898-4225
Practice Address - Fax:920-898-4597
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38943700OtherMEDICAL ASSISTANCE
WIU56504Medicare ID - Type Unspecified