Provider Demographics
NPI:1790142107
Name:LIBBY, JACOB (OTRL)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E CHICAGO RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-8524
Mailing Address - Country:US
Mailing Address - Phone:269-659-4468
Mailing Address - Fax:269-659-2744
Practice Address - Street 1:1717 E CHICAGO RD
Practice Address - Street 2:SUITE 1
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8524
Practice Address - Country:US
Practice Address - Phone:269-659-4468
Practice Address - Fax:269-659-2744
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007506225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201007506OtherMICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS