Provider Demographics
NPI:1033670104
Name:FREDRICKSON, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FREDRICKSON
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 1:4691 BRIONES VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4917
Mailing Address - Country:US
Mailing Address - Phone:925-470-6444
Mailing Address - Fax:
Practice Address - Street 1:4501 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8687
Practice Address - Country:US
Practice Address - Phone:925-813-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist