Provider Demographics
NPI:1881023539
Name:GROSETH, JACOB WESLEY (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WESLEY
Last Name:GROSETH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:GROSETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:280 EXEMPLA CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3370
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:463688 STATE ROAD 200 STE 9
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-0304
Practice Address - Country:US
Practice Address - Phone:904-261-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL145866363AS0400X
FLPT33205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical