Provider Demographics
NPI:1043500705
Name:JACOB, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:NINAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:705 S MAIN ST
Mailing Address - Street 2:STE. 220
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2089
Mailing Address - Country:US
Mailing Address - Phone:734-354-8000
Mailing Address - Fax:
Practice Address - Street 1:705 S MAIN ST
Practice Address - Street 2:STE. 220
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2089
Practice Address - Country:US
Practice Address - Phone:734-354-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011891225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist