Provider Demographics
NPI:1265008841
Name:BIRKHEAD, JACOB HENRY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:HENRY
Last Name:BIRKHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 W WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1883
Mailing Address - Country:US
Mailing Address - Phone:919-943-8969
Mailing Address - Fax:
Practice Address - Street 1:110 W KING ST STE 2
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3437
Practice Address - Country:US
Practice Address - Phone:704-739-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19139225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist