Provider Demographics
NPI:1770631350
Name:THEROUX, JESSICA MARIE (ATC, CSCS)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:MARIE
Last Name:THEROUX
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1605 SWAN RD
Mailing Address - Street 2:APT 1
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8499
Mailing Address - Country:US
Mailing Address - Phone:920-265-0443
Mailing Address - Fax:
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-991-2561
Practice Address - Fax:920-991-2563
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI465-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer