Provider Demographics
NPI:1457580482
Name:JACOB, SANJITH (PT)
Entity Type:Individual
Prefix:MR
First Name:SANJITH
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141206
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-6206
Mailing Address - Country:US
Mailing Address - Phone:248-416-9927
Mailing Address - Fax:
Practice Address - Street 1:16891 DOVER DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-6506
Practice Address - Country:US
Practice Address - Phone:248-416-9927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist