Provider Demographics
NPI:1497518955
Name:WILLIAMS, JACOB BRADLEY (LMT, MMT, NMT, CLT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BRADLEY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LMT, MMT, NMT, CLT
Other - Prefix:
Other - First Name:JACOBI
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, MMT, NMT, CLT
Mailing Address - Street 1:1530 JOHNSTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2831
Mailing Address - Country:US
Mailing Address - Phone:231-510-0863
Mailing Address - Fax:
Practice Address - Street 1:700 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8220
Practice Address - Country:US
Practice Address - Phone:231-510-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501014520225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist