Provider Demographics
NPI:1306446489
Name:SOULOUQUE, JEPTHE (MS LAT ATC)
Entity type:Individual
Prefix:
First Name:JEPTHE
Middle Name:
Last Name:SOULOUQUE
Suffix:
Gender:M
Credentials:MS LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1820
Mailing Address - Country:US
Mailing Address - Phone:617-913-6113
Mailing Address - Fax:
Practice Address - Street 1:235 BAKER ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4395
Practice Address - Country:US
Practice Address - Phone:617-469-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA305442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer