Provider Demographics
NPI:1245064377
Name:KLEBAR, JACOB JOHN (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:KLEBAR
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6236 HOLLY SPRINGS PKWY STE D8
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-2426
Practice Address - Country:US
Practice Address - Phone:770-800-6770
Practice Address - Fax:770-800-1223
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist