Provider Demographics
NPI:1225064553
Name:VEENSTRA, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VEENSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PETER ROBERTSON BLVD.
Mailing Address - Street 2:UNIT 15
Mailing Address - City:BRAMPTON
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L6R 1T4
Mailing Address - Country:CA
Mailing Address - Phone:905-793-8868
Mailing Address - Fax:
Practice Address - Street 1:630 PETER ROBERTSON BLVD.
Practice Address - Street 2:UNIT 15
Practice Address - City:BRAMPTON
Practice Address - State:ONTARIO
Practice Address - Zip Code:L6R 1T4
Practice Address - Country:CA
Practice Address - Phone:905-793-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3092266Medicaid
TNG15071Medicare UPIN
TN3092266Medicare ID - Type UnspecifiedINDIVIDUAL
TN3716560Medicare ID - Type UnspecifiedGROUP