Provider Demographics
NPI:1619501442
Name:BOUCHER, JACOB PAUL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PAUL
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ALFORD PARK DR
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1927
Mailing Address - Country:US
Mailing Address - Phone:262-424-5253
Mailing Address - Fax:
Practice Address - Street 1:1235 DAKOTA DR STE L
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9477
Practice Address - Country:US
Practice Address - Phone:262-376-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17078-242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic