Provider Demographics
NPI:1720654940
Name:SHIELDS, JACOB (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7010
Mailing Address - Country:US
Mailing Address - Phone:517-990-6210
Mailing Address - Fax:517-990-6212
Practice Address - Street 1:8741 W SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7752
Practice Address - Country:US
Practice Address - Phone:517-925-8825
Practice Address - Fax:517-990-6212
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501020040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC80776OtherBCBS