Provider Demographics
NPI:1861565814
Name:JACQUETTE CHIROPRACTIC SC
Entity type:Organization
Organization Name:JACQUETTE CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-781-3332
Mailing Address - Street 1:13740 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2407
Mailing Address - Country:US
Mailing Address - Phone:262-781-3332
Mailing Address - Fax:262-781-6477
Practice Address - Street 1:13740 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2407
Practice Address - Country:US
Practice Address - Phone:262-781-3332
Practice Address - Fax:262-781-6477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38999000Medicaid