Provider Demographics
NPI:1568147239
Name:SPIESS, JACOB SCOTT
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SCOTT
Last Name:SPIESS
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 1:6314 BERKEY SOUTHERN RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43571-9742
Mailing Address - Country:US
Mailing Address - Phone:419-508-2357
Mailing Address - Fax:
Practice Address - Street 1:6230 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7022
Practice Address - Country:US
Practice Address - Phone:616-698-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010029012081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine