Healthcare Provider Details

I. General information

NPI: 1740152040
Provider Name (Legal Business Name): JACQUES COURSEAULT, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N CRESCENT DR STE 130
BEVERLY HILLS CA
90210-6816
US

IV. Provider business mailing address

415 N CRESCENT DR STE 130
BEVERLY HILLS CA
90210-6816
US

V. Phone/Fax

Practice location:
  • Phone: 424-378-3488
  • Fax: 800-881-2038
Mailing address:
  • Phone: 424-378-3488
  • Fax: 800-881-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUES COURSEAULT
Title or Position: CEO
Credential: MD, CAQSM
Phone: 424-378-3488