Provider Demographics
NPI:1366121782
Name:NOVAK, JACOB AUGUST (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AUGUST
Last Name:NOVAK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 LAKEVIEW DR APT 4
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1630
Mailing Address - Country:US
Mailing Address - Phone:734-904-3323
Mailing Address - Fax:
Practice Address - Street 1:17110 W GREENFIELD AVE STE 7
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6947
Practice Address - Country:US
Practice Address - Phone:262-297-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1645024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist