Healthcare Provider Details

I. General information

NPI: 1093369589
Provider Name (Legal Business Name): JACOB CANRIGHT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 W KIMBERLY RD
DAVENPORT IA
52806-3059
US

IV. Provider business mailing address

3200 W KIMBERLY RD
DAVENPORT IA
52806-3059
US

V. Phone/Fax

Practice location:
  • Phone: 563-421-0300
  • Fax: 563-421-0309
Mailing address:
  • Phone: 563-421-0300
  • Fax: 563-421-0309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number070.022579
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: