Provider Demographics
NPI:1841926920
Name:DUSSEAU, JACQUELINE G (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:G
Last Name:DUSSEAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3886 CALIBRE BEND LN APT 808
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8648
Mailing Address - Country:US
Mailing Address - Phone:248-342-0955
Mailing Address - Fax:
Practice Address - Street 1:3886 CALIBRE BEND LN APT 808
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8648
Practice Address - Country:US
Practice Address - Phone:248-342-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001844225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502001844OtherPHYSICAL THERAPIST ASSISTANT