Provider Demographics
NPI:1417660937
Name:LEDOCQ, JADE J (OTR)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:J
Last Name:LEDOCQ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9499 COUNTY ROAD P
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54213-9506
Mailing Address - Country:US
Mailing Address - Phone:920-255-5375
Mailing Address - Fax:
Practice Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4860
Practice Address - Country:US
Practice Address - Phone:920-255-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR466578225X00000X
WI7176225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist