Provider Demographics
NPI:1629367776
Name:CLEARFIELD, JACOB STEVEN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:STEVEN
Last Name:CLEARFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:STEVEN
Other - Last Name:DICKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3811 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-6262
Mailing Address - Fax:262-687-6261
Practice Address - Street 1:3811 SPRING ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-6262
Practice Address - Fax:262-687-6261
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60013208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400223967Medicare UPIN