Provider Demographics
NPI:1801828272
Name:MUTHOLAM, JACOB (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MUTHOLAM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 W COLLEGE DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1785
Mailing Address - Country:US
Mailing Address - Phone:708-489-6777
Mailing Address - Fax:708-489-6303
Practice Address - Street 1:6400 W COLLEGE DR
Practice Address - Street 2:SUITE 800
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1785
Practice Address - Country:US
Practice Address - Phone:708-489-6777
Practice Address - Fax:708-489-6303
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-004073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist