Provider Demographics
NPI:1740044429
Name:JOA, JACOB M (RDN)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:M
Last Name:JOA
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4723 WOBURN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1767
Mailing Address - Country:US
Mailing Address - Phone:248-259-4640
Mailing Address - Fax:
Practice Address - Street 1:4723 WOBURN DR
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1767
Practice Address - Country:US
Practice Address - Phone:248-259-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86155395133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered