Provider Demographics
NPI:1821271016
Name:CAPOUCH, JENNY DARICE
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:DARICE
Last Name:CAPOUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-2133
Mailing Address - Country:US
Mailing Address - Phone:608-249-7622
Mailing Address - Fax:
Practice Address - Street 1:805 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-8912
Practice Address - Country:US
Practice Address - Phone:608-839-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI971-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant