Provider Demographics
NPI:1568138576
Name:TODD, JACOB E (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:TODD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2328
Mailing Address - Country:US
Mailing Address - Phone:701-403-9853
Mailing Address - Fax:
Practice Address - Street 1:1435 S MAPLE GROVE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1611
Practice Address - Country:US
Practice Address - Phone:208-332-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT-7512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist