Healthcare Provider Details

I. General information

NPI: 1578758009
Provider Name (Legal Business Name): MR. ERIC G JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 10TH ST SE
CEDAR RAPIDS IA
52403-1251
US

IV. Provider business mailing address

1300 GODWARD ST NE STE 6250
MINNEAPOLIS MN
55413-2561
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-6011
  • Fax: 319-398-6509
Mailing address:
  • Phone: 800-303-8189
  • Fax: 612-378-7526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00757
License Number StateIA

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: