Provider Demographics
NPI:1477515989
Name:DAVIDE, JAY JOSEPH (LAT)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:JOSEPH
Last Name:DAVIDE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-1045
Mailing Address - Country:US
Mailing Address - Phone:920-339-0233
Mailing Address - Fax:
Practice Address - Street 1:820 E GRANT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3483
Practice Address - Country:US
Practice Address - Phone:920-716-8137
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1640392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer