Provider Demographics
NPI:1093004426
Name:JACOB, PIUS (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PIUS
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13439 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-6304
Mailing Address - Country:US
Mailing Address - Phone:586-977-3900
Mailing Address - Fax:586-977-3900
Practice Address - Street 1:13439 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6304
Practice Address - Country:US
Practice Address - Phone:586-977-3900
Practice Address - Fax:586-977-3900
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501011904OtherSTATE LICENSE