Healthcare Provider Details

I. General information

NPI: 1497448187
Provider Name (Legal Business Name): JACOB HOLT PT, DPT, AT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 GRISWOLD ST SE
GRAND RAPIDS MI
49507-3815
US

IV. Provider business mailing address

1002 W BROOMFIELD ST APT 8C
MOUNT PLEASANT MI
48858-4530
US

V. Phone/Fax

Practice location:
  • Phone: 616-207-3861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501302468
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: