Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 13622 | WI |
NPI | 1073060521 |
---|---|
Provider Name | Kerry Jacquet |
First Address | Kenosha, WI 53144-7468 |
Second Address | Kenosha, WI 53144-7468 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 24/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1073060521 | (05) | WI |