Provider Demographics
NPI:1659958783
Name:GRICAR, JACOB JOHN (PT, DPT, LAT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:JOHN
Last Name:GRICAR
Suffix:
Gender:M
Credentials:PT, DPT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2550
Mailing Address - Fax:
Practice Address - Street 1:13250 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1516
Practice Address - Country:US
Practice Address - Phone:262-799-8330
Practice Address - Fax:262-799-8331
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2025-08-06
Deactivation Date:2025-06-16
Deactivation Code:
Reactivation Date:2025-07-28
Provider Licenses
StateLicense IDTaxonomies
WI17322-24225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100366844Medicaid