Provider Demographics
NPI:1205350865
Name:BIRDSALL, JACOB R (D-PT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:BIRDSALL
Suffix:
Gender:M
Credentials:D-PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 N PARK DRIVE LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1603
Mailing Address - Country:US
Mailing Address - Phone:920-380-4999
Mailing Address - Fax:920-380-4961
Practice Address - Street 1:2809 N PARK DRIVE LN
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1603
Practice Address - Country:US
Practice Address - Phone:920-830-4999
Practice Address - Fax:920-380-4961
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13915-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist