Provider Demographics
NPI:1982102786
Name:BLACKMER, JACOB (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BLACKMER
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 ANN ARBOR RD W STE 666
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2129
Mailing Address - Country:US
Mailing Address - Phone:231-923-6349
Mailing Address - Fax:
Practice Address - Street 1:324 S JAMES ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2106
Practice Address - Country:US
Practice Address - Phone:231-923-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist