Provider Demographics
NPI:1316603004
Name:WIPF, JACOB (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WIPF
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 BENT TWIG AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5189
Mailing Address - Country:US
Mailing Address - Phone:805-312-5374
Mailing Address - Fax:
Practice Address - Street 1:231 CAMARILLO RANCH RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5082
Practice Address - Country:US
Practice Address - Phone:805-484-2026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA301371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT301371OtherCA LICENSE