Provider Demographics
NPI:1295250744
Name:JACOB, EMILY (ATC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5829 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-3113
Mailing Address - Country:US
Mailing Address - Phone:612-978-0313
Mailing Address - Fax:
Practice Address - Street 1:5829 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-3113
Practice Address - Country:US
Practice Address - Phone:612-978-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer