Healthcare Provider Details

I. General information

NPI: 1780186346
Provider Name (Legal Business Name): PHILIP L JAHN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 RAYBROOK ST SE
GRAND RAPIDS MI
49546-5793
US

IV. Provider business mailing address

2809 RIVER RD
TWIN LAKE MI
49457-8826
US

V. Phone/Fax

Practice location:
  • Phone: 616-235-3115
  • Fax:
Mailing address:
  • Phone: 231-750-0719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000435
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: