Provider Demographics
NPI:1780186346
Name:JAHN, PHILIP L (PTA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:L
Last Name:JAHN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49457-8826
Mailing Address - Country:US
Mailing Address - Phone:231-750-0719
Mailing Address - Fax:
Practice Address - Street 1:2121 RAYBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5793
Practice Address - Country:US
Practice Address - Phone:616-235-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000435225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant