Provider Demographics
NPI:1184310930
Name:MEDVIDOVICH, JACOB (AMNT, CMT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MEDVIDOVICH
Suffix:
Gender:M
Credentials:AMNT, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18701 VIERRA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93907-1346
Mailing Address - Country:US
Mailing Address - Phone:717-645-9949
Mailing Address - Fax:
Practice Address - Street 1:550 WATER ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4124
Practice Address - Country:US
Practice Address - Phone:717-645-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75498225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist