Provider Demographics
NPI:1154711828
Name:GARRISON, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GARRISON
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 1:2S814 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-9368
Mailing Address - Country:US
Mailing Address - Phone:630-639-7879
Mailing Address - Fax:
Practice Address - Street 1:2S814 WAGNER RD
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-9368
Practice Address - Country:US
Practice Address - Phone:630-639-7879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist