Provider Demographics
NPI:1821527003
Name:RETZER, JACOB P (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:RETZER
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 1:1615 CAPITOL WAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-2218
Mailing Address - Country:US
Mailing Address - Phone:701-451-0410
Mailing Address - Fax:
Practice Address - Street 1:1615 CAPITOL WAY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-2218
Practice Address - Country:US
Practice Address - Phone:701-451-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist