Healthcare Provider Details

I. General information

NPI: 1790639656
Provider Name (Legal Business Name): JACOB WHITE-SEABLOOM PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 GRANT ST
BETTENDORF IA
52722-5092
US

IV. Provider business mailing address

4509 22ND AVE
MOLINE IL
61265-4513
US

V. Phone/Fax

Practice location:
  • Phone: 563-359-9171
  • Fax:
Mailing address:
  • Phone: 309-373-5943
  • Fax: 309-373-5943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number129785
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: