Provider Demographics
NPI:1972083731
Name:KNIERIM, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KNIERIM
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 1:2207 UNIVERSITY COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:WV
Mailing Address - Zip Code:26505-0212
Mailing Address - Country:US
Mailing Address - Phone:304-231-7593
Mailing Address - Fax:
Practice Address - Street 1:1031 MORGANTOWN AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4355
Practice Address - Country:US
Practice Address - Phone:304-363-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist