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General NPI Number Information
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NPI Number | 1619501442
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Entity Type | Individual
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Provider Name | JACOB PAUL BOUCHER
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Gender | Male
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Dates
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Enumeration Date | 03/02/2020
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Last Update Date | 03/27/2025
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Provider Practice Location Address
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Address Line | 1235 DAKOTA DR STE L
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City | GRAFTON
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State | WI
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Zip | 53024-9477
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Country | US
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Telephone | 262-376-2085
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Fax |
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Provider Business Mailing Address
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Address Line | 2001 ALFORD PARK DR
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City | KENOSHA
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State | WI
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Zip | 53140-1927
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Country | US
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Telephone | 262-424-5253
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 17078-24
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License Number State | WI
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