Healthcare Provider Details

I. General information

NPI: 1689620643
Provider Name (Legal Business Name): JACOB BARRETT ARVIDSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E BOGARD RD
WASILLA AK
99654-7108
US

IV. Provider business mailing address

401 E BOGARD RD
WASILLA AK
99654-7108
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-2578
  • Fax: 907-357-2529
Mailing address:
  • Phone: 907-357-2578
  • Fax: 907-357-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1704
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: