Provider Demographics
NPI:1578980306
Name:DAVIS, JACOB (LMT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 YANKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LYTTON
Mailing Address - State:IA
Mailing Address - Zip Code:50561-7587
Mailing Address - Country:US
Mailing Address - Phone:712-210-1649
Mailing Address - Fax:
Practice Address - Street 1:322 W 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2708
Practice Address - Country:US
Practice Address - Phone:712-775-2418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005997225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist