Provider Demographics
NPI:1588131767
Name:JOUBERT, EZEKIEL JR
Entity type:Individual
Prefix:MR
First Name:EZEKIEL
Middle Name:
Last Name:JOUBERT
Suffix:JR
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 1:24261 ELWELL RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-9412
Mailing Address - Country:US
Mailing Address - Phone:734-548-0294
Mailing Address - Fax:
Practice Address - Street 1:24261 ELWELL RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-9412
Practice Address - Country:US
Practice Address - Phone:734-548-0294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2362222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer