Provider Demographics
NPI:1659958783
Name:GRICAR, JACOB JOHN (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:JOHN
Last Name:GRICAR
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15312 W BELOIT RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7447
Mailing Address - Country:US
Mailing Address - Phone:262-641-5771
Mailing Address - Fax:262-641-6317
Practice Address - Street 1:15312 W BELOIT RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7447
Practice Address - Country:US
Practice Address - Phone:262-641-5771
Practice Address - Fax:262-641-6317
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer