Provider Demographics
NPI:1326745563
Name:PARENTEAU, JACOB CHARLES (LMT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CHARLES
Last Name:PARENTEAU
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CROSSRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405
Mailing Address - Country:US
Mailing Address - Phone:262-909-8043
Mailing Address - Fax:
Practice Address - Street 1:5401 DOUGLAS AVE
Practice Address - Street 2:SUITE# A
Practice Address - City:CALEDONIA
Practice Address - State:WI
Practice Address - Zip Code:53402
Practice Address - Country:US
Practice Address - Phone:262-681-8829
Practice Address - Fax:262-681-8830
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14809225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist