Healthcare Provider Details

I. General information

NPI: 1497518955
Provider Name (Legal Business Name): JACOB BRADLEY WILLIAMS LMT, MMT, NMT, CLT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACOBI WILLIAMS LMT, MMT, NMT, CLT

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 3 MILE RD NW
GRAND RAPIDS MI
49544-8220
US

IV. Provider business mailing address

1530 JOHNSTON ST SE
GRAND RAPIDS MI
49507-2831
US

V. Phone/Fax

Practice location:
  • Phone: 231-510-8630
  • Fax:
Mailing address:
  • Phone: 231-510-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501014520
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: