Provider Demographics
NPI:1114083912
Name:JACOT, DOUGLAS EARL (DC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EARL
Last Name:JACOT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 TENTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002
Mailing Address - Country:US
Mailing Address - Phone:715-684-3344
Mailing Address - Fax:715-684-3345
Practice Address - Street 1:1640 TENTH AVENUE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002
Practice Address - Country:US
Practice Address - Phone:715-684-3344
Practice Address - Fax:715-684-3345
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38758200Medicaid
WI38758200Medicaid