Provider Demographics
NPI:1437520343
Name:HERBERGER, JACOB (DPT, CSCS, ATC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:HERBERGER
Suffix:
Gender:M
Credentials:DPT, CSCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:6187 S ARCHER AVE STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2812
Practice Address - Country:US
Practice Address - Phone:773-500-2620
Practice Address - Fax:773-500-2630
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960043792255A2300X
IL070025148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty