Provider Demographics
NPI:1902128622
Name:JACQUES, KACEY (PT)
Entity Type:Individual
Prefix:MS
First Name:KACEY
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 VARIEL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-2514
Mailing Address - Country:US
Mailing Address - Phone:818-888-1255
Mailing Address - Fax:
Practice Address - Street 1:1889 WOODMOOR DR
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9066
Practice Address - Country:US
Practice Address - Phone:719-481-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA145312251E1200X, 2251P0200X, 2251S0007X, 2251X0800X
COPTL0015090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic