Provider Demographics
NPI:1457017386
Name:ROUTHIER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROUTHIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PELL MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-2962
Mailing Address - Country:US
Mailing Address - Phone:203-258-1932
Mailing Address - Fax:
Practice Address - Street 1:160 E ATHLETICS WAY
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5068
Practice Address - Country:US
Practice Address - Phone:203-258-1932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0089662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer