Provider Demographics
NPI:1003302068
Name:CARMICHAEL, JACOB (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:CARMICHAEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6247
Mailing Address - Country:US
Mailing Address - Phone:814-201-2309
Mailing Address - Fax:814-201-2389
Practice Address - Street 1:914 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6247
Practice Address - Country:US
Practice Address - Phone:814-201-2309
Practice Address - Fax:814-201-2389
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC007231213EP1101X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program