Provider Demographics
NPI:1588201289
Name:GRACE, JACQUELINE ANN
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:GRACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SPRINGBROOK RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-5703
Mailing Address - Country:US
Mailing Address - Phone:262-515-6608
Mailing Address - Fax:
Practice Address - Street 1:3201 SPRINGBROOK RD
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-5703
Practice Address - Country:US
Practice Address - Phone:262-515-6608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer