Provider Demographics
NPI:1235587783
Name:JAGUSH, NICHOLAS (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JAGUSH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 53RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7565
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:
Practice Address - Street 1:510 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6133
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA085961225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA085961OtherLICENSE
IL070022544OtherLICENSE