Healthcare Provider Details

I. General information

NPI: 1871938217
Provider Name (Legal Business Name): JACOB RICHARD PETWAY DC, QME, IIE, BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 AZUSA ST
SACRAMENTO CA
95833-2328
US

IV. Provider business mailing address

929 AZUSA ST
SACRAMENTO CA
95833-2328
US

V. Phone/Fax

Practice location:
  • Phone: 530-315-5594
  • Fax:
Mailing address:
  • Phone: 530-315-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number32615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: