Provider Demographics
NPI:1922586080
Name:WALTZ, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14930 LAPLAISANCE RD
Mailing Address - Street 2:STE 116
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-3871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14930 LAPLAISANCE RD
Practice Address - Street 2:STE 116
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3871
Practice Address - Country:US
Practice Address - Phone:734-242-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor