Provider Demographics
NPI:1710674783
Name:KNOWLTON, JACOB ROBERT
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:KNOWLTON
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 1:428 BAYBERRY POINTE DR NW APT F
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4643
Mailing Address - Country:US
Mailing Address - Phone:231-327-8231
Mailing Address - Fax:
Practice Address - Street 1:231 ALBERT SABIN WAY, ML 0558
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-0558
Practice Address - Country:US
Practice Address - Phone:513-558-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program