Provider Demographics
NPI:1184045031
Name:ANDERSON, JACOB MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:ANDERSON
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 1:767 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201
Mailing Address - Country:US
Mailing Address - Phone:309-788-7631
Mailing Address - Fax:
Practice Address - Street 1:767 30TH STREET
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-788-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist