Provider Demographics
NPI:1588303952
Name:SOUVA, JACOB BRAD
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRAD
Last Name:SOUVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71575 JULIUS DR
Mailing Address - Street 2:
Mailing Address - City:BRUCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48065-3187
Mailing Address - Country:US
Mailing Address - Phone:586-569-1621
Mailing Address - Fax:
Practice Address - Street 1:2615 NAKOTA RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1816
Practice Address - Country:US
Practice Address - Phone:586-210-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501301913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist