Healthcare Provider Details

I. General information

NPI: 1902521206
Provider Name (Legal Business Name): JACOB FICKEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 COLONIAL CT
HOLLAND MI
49423-5232
US

IV. Provider business mailing address

1103 COLONIAL CT
HOLLAND MI
49423-5232
US

V. Phone/Fax

Practice location:
  • Phone: 616-990-5701
  • Fax:
Mailing address:
  • Phone: 616-990-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502002938
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: