Provider Demographics
NPI:1588827869
Name:BANQUICIO, JAN E (OTR)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:E
Last Name:BANQUICIO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 GULF SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4898
Mailing Address - Country:US
Mailing Address - Phone:765-864-0813
Mailing Address - Fax:
Practice Address - Street 1:429 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3508
Practice Address - Country:US
Practice Address - Phone:765-453-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004083A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist