Provider Demographics
NPI:1699737288
Name:DINAUER, JACOB R (MED, ATC, EMT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:R
Last Name:DINAUER
Suffix:
Gender:M
Credentials:MED, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3526 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53108-9749
Mailing Address - Country:US
Mailing Address - Phone:262-939-6560
Mailing Address - Fax:262-551-5995
Practice Address - Street 1:2001 ALFORD PARK DR
Practice Address - Street 2:TARC 1150
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1929
Practice Address - Country:US
Practice Address - Phone:262-551-6107
Practice Address - Fax:262-551-5995
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304299146M00000X
WI103-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer