Provider Demographics
NPI:1346833241
Name:ROCKWELL, JACOB (LAC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROCKWELL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 NE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3859
Mailing Address - Country:US
Mailing Address - Phone:971-506-4236
Mailing Address - Fax:
Practice Address - Street 1:4943 NE MLK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3353
Practice Address - Country:US
Practice Address - Phone:971-506-4236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC203512171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist