Provider Demographics
NPI:1528699667
Name:GOLEMBESKI, JACOB (MS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GOLEMBESKI
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 EMERSON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1419
Practice Address - Country:US
Practice Address - Phone:812-207-8903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty