Provider Demographics
NPI:1992297949
Name:HART, JACOB (DPT)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:HART
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 1:4401 CAMPUS RIDGE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6125
Mailing Address - Country:US
Mailing Address - Phone:989-837-9136
Mailing Address - Fax:989-837-9105
Practice Address - Street 1:4401 CAMPUS RIDGE DR STE 1000
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6125
Practice Address - Country:US
Practice Address - Phone:989-837-9136
Practice Address - Fax:989-837-9105
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist