Provider Demographics
NPI:1023541927
Name:DAVIS, JACOB ANDREW
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:DAVIS
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 1:304 GLEN CARIN DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9395
Mailing Address - Country:US
Mailing Address - Phone:616-481-1357
Mailing Address - Fax:
Practice Address - Street 1:304 GLEN CARIN DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9395
Practice Address - Country:US
Practice Address - Phone:616-481-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner