Healthcare Provider Details

I. General information

NPI: 1952597486
Provider Name (Legal Business Name): PETER JOHN JACQUES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4652 GLENN ST
APPLETON WI
54913-9563
US

IV. Provider business mailing address

W4652 GLENN ST
APPLETON WI
54913-9563
US

V. Phone/Fax

Practice location:
  • Phone: 920-540-8840
  • Fax: 866-878-1996
Mailing address:
  • Phone: 920-540-8840
  • Fax: 866-878-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3448024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER JOHN JACQUES
Title or Position: OWNER CEO
Credential: PT
Phone: 920-540-8840