Provider Demographics
NPI:1386317592
Name:DUBOIS, JARED MATTHEW (PTA)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:MATTHEW
Last Name:DUBOIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2894 GREEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-0621
Mailing Address - Country:US
Mailing Address - Phone:715-820-3134
Mailing Address - Fax:
Practice Address - Street 1:400 DERONDA ST
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1404
Practice Address - Country:US
Practice Address - Phone:715-268-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty