Provider Demographics
NPI:1629291877
Name:OVERPECK, JACQUELINE MARIE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:OVERPECK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2703
Mailing Address - Country:US
Mailing Address - Phone:812-274-4040
Mailing Address - Fax:
Practice Address - Street 1:2420 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2135
Practice Address - Country:US
Practice Address - Phone:812-265-8226
Practice Address - Fax:812-265-8227
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008585A225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200857980Medicaid
KY7100168390Medicaid