Provider Demographics
NPI:1265607782
Name:JACOB, BABITHA (PT)
Entity type:Individual
Prefix:
First Name:BABITHA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BABITHA
Other - Middle Name:
Other - Last Name:JOSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400 - CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-465-0100
Mailing Address - Fax:
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2647
Practice Address - Country:US
Practice Address - Phone:248-465-0100
Practice Address - Fax:248-465-0107
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist