Healthcare Provider Details

I. General information

NPI: 1831160381
Provider Name (Legal Business Name): JACOB CLIFFORD WEBER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 COLLEGE BLVD
CARMI IL
62821-1548
US

IV. Provider business mailing address

1304 CYPRESS RD
OLNEY IL
62450-4339
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-2923
  • Fax:
Mailing address:
  • Phone: 618-925-3973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-013499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: