Provider Demographics
NPI:1639233034
Name:BOGUCKE, JACQUELINE ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:BOGUCKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COMBE ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9221
Mailing Address - Country:US
Mailing Address - Phone:920-748-2703
Mailing Address - Fax:
Practice Address - Street 1:2300 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-9137
Practice Address - Country:US
Practice Address - Phone:920-233-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4368-024174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4368-024OtherWI DEPARTMENT OF REG.