Provider Demographics
NPI:1649380528
Name:JACQUETTE, MARK R (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JACQUETTE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13740 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2407
Mailing Address - Country:US
Mailing Address - Phone:262-781-3332
Mailing Address - Fax:262-781-6477
Practice Address - Street 1:13740 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2407
Practice Address - Country:US
Practice Address - Phone:262-781-3332
Practice Address - Fax:262-781-6477
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38787800Medicaid
WIT62298Medicare UPIN