Provider Demographics
NPI:1255712311
Name:JACKSON, HILLARY DIANE (DPT)
Entity type:Individual
Prefix:MRS
First Name:HILLARY
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:HILLARY
Other - Middle Name:DIANE
Other - Last Name:GRUSZKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1532 S GREEN BAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4468
Mailing Address - Country:US
Mailing Address - Phone:262-321-0240
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:241 N BROADWAY STE 403
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5819
Practice Address - Country:US
Practice Address - Phone:414-446-9291
Practice Address - Fax:414-446-8618
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12713-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist