Healthcare Provider Details

I. General information

NPI: 1285426023
Provider Name (Legal Business Name): JACOB MICHAEL PELAK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49504-8042
US

IV. Provider business mailing address

6902 HIGHLAND DR E
ALLENDALE MI
49401-8637
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-0408
  • Fax:
Mailing address:
  • Phone: 616-916-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502006430
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: