Provider Demographics
NPI:1629046826
Name:PEQUETTE, JASON SCOTT (MS,ATC,CSCS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:SCOTT
Last Name:PEQUETTE
Suffix:
Gender:M
Credentials:MS,ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:790 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4909
Practice Address - Country:US
Practice Address - Phone:630-269-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0010432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer