Healthcare Provider Details

I. General information

NPI: 1952191561
Provider Name (Legal Business Name): JACOB COUILLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3595
US

IV. Provider business mailing address

205 4TH ST
GOODMAN WI
54125-9752
US

V. Phone/Fax

Practice location:
  • Phone: 414-777-7700
  • Fax:
Mailing address:
  • Phone: 906-221-9384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: