Provider Demographics
NPI:1669887097
Name:DUNKERSON, JACOB (MSOT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DUNKERSON
Suffix:
Gender:M
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 HERMANSAU DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 HERMANSAU DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2520
Practice Address - Country:US
Practice Address - Phone:810-869-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008869225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist