Provider Demographics
NPI:1699717520
Name:JACQUES, PETER J (PT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:J
Last Name:JACQUES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4652 GLENN ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9563
Mailing Address - Country:US
Mailing Address - Phone:920-540-8840
Mailing Address - Fax:
Practice Address - Street 1:W4652 GLENN ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9563
Practice Address - Country:US
Practice Address - Phone:920-540-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3448-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41750700Medicaid
WI40299600Medicaid