Provider Demographics
NPI:1184339988
Name:WILLIS, JACOB STEVEN (OTR/L)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:STEVEN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 SEQUALITCHEW DR # M-302
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-6847
Mailing Address - Country:US
Mailing Address - Phone:540-246-2923
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61507906225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist