Provider Demographics
NPI:1245345628
Name:DUFAULT, JESSICA (DPT, ATC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:DUFAULT
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3513
Mailing Address - Country:US
Mailing Address - Phone:608-512-3769
Mailing Address - Fax:
Practice Address - Street 1:305 S LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3513
Practice Address - Country:US
Practice Address - Phone:608-512-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5232225100000X
WI11909-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist