Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PTL0015090 | CO |
N | 2251E1200X | Ergonomics | 14531 | CA |
N | 225XE1200X | Ergonomics | 14531 | CA |
N | 2251P0200X | Physical Therapist - Pediatrics | 14531 | CA |
N | 2251S0007X | Physical Therapist - Sports | 14531 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | 14531 | CA |
NPI | 1902128622 |
---|---|
Provider Name | Ms. Kacey Jacques |
First Address | Woodland Hills, CA 91367-2514 |
Second Address | Monument, CO 80132-9066 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2010 |
Last Update Date | 20/10/2021 |