Provider Demographics
NPI:1578043089
Name:KMIECIK, JACOB JOHN (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:KMIECIK
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 1:5450 LEARY AVE NW APT 643
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4081
Mailing Address - Country:US
Mailing Address - Phone:402-350-3146
Mailing Address - Fax:
Practice Address - Street 1:1218 3RD AVE STE 104
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-3008
Practice Address - Country:US
Practice Address - Phone:206-447-2220
Practice Address - Fax:206-447-2228
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60852959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist