Provider Demographics
NPI:1568831139
Name:BLOOD, JACOB (DPT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:BLOOD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4772 CADDIE LANE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003
Mailing Address - Country:US
Mailing Address - Phone:650-804-9300
Mailing Address - Fax:
Practice Address - Street 1:636 E STATE RD
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2151
Practice Address - Country:US
Practice Address - Phone:801-492-6577
Practice Address - Fax:801-402-6579
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9517246-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist