Healthcare Provider Details

I. General information

NPI: 1528525920
Provider Name (Legal Business Name): JACOB STEVEN LAVERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

IV. Provider business mailing address

7151 HATTERAS LN APT 1D
INDIANAPOLIS IN
46214-1267
US

V. Phone/Fax

Practice location:
  • Phone: 712-461-0244
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002972A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number05012967A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: