Provider Demographics
NPI:1689311326
Name:WOOLLEY, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WOOLLEY
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 1:4043 CHATSWORTH ST N UNIT 449
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5502
Mailing Address - Country:US
Mailing Address - Phone:817-808-6638
Mailing Address - Fax:
Practice Address - Street 1:4043 CHATSWORTH ST N UNIT 449
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5502
Practice Address - Country:US
Practice Address - Phone:817-808-6638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer