Provider Demographics
NPI:1831656339
Name:KEARY, JACOB (AT, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KEARY
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 ARBOR CIR W APT 103
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3453
Mailing Address - Country:US
Mailing Address - Phone:785-312-0294
Mailing Address - Fax:
Practice Address - Street 1:799 N HEWITT RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1701
Practice Address - Country:US
Practice Address - Phone:785-312-0294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010024652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer