Provider Demographics
NPI:1780203661
Name:ERWIN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ERWIN
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 1:38 SILVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PORT DOVER
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N0A 1N6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 SILVER LAKE DR
Practice Address - Street 2:
Practice Address - City:PORT DOVER
Practice Address - State:ONTARIO
Practice Address - Zip Code:N0A 1N6
Practice Address - Country:CA
Practice Address - Phone:802-342-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer