Provider Demographics
NPI:1538317920
Name:JACQUIN, EDWARD V (P T)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:V
Last Name:JACQUIN
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 WOODWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3031
Mailing Address - Country:US
Mailing Address - Phone:636-349-1768
Mailing Address - Fax:
Practice Address - Street 1:947 WOODWAY DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3031
Practice Address - Country:US
Practice Address - Phone:636-349-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist