Provider Demographics
NPI:1346601796
Name:JACOBS, CHAD ALAN (LPTA)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ALAN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:KAWKAWLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48631-9784
Mailing Address - Country:US
Mailing Address - Phone:989-326-5602
Mailing Address - Fax:
Practice Address - Street 1:2404 9 MILE RD
Practice Address - Street 2:
Practice Address - City:KAWKAWLIN
Practice Address - State:MI
Practice Address - Zip Code:48631-9784
Practice Address - Country:US
Practice Address - Phone:989-326-5602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000705225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant