Provider Demographics
NPI:1184591992
Name:JACAK, BECKY
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:JACAK
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 1:715 HILL ST STE 270
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:608-237-2111
Practice Address - Street 1:715 HILL ST STE 270
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3572
Practice Address - Country:US
Practice Address - Phone:608-616-0264
Practice Address - Fax:608-237-2111
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10050-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty