Healthcare Provider Details

I. General information

NPI: 1346802253
Provider Name (Legal Business Name): JACOB ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S BIRCH ST
KALKASKA MI
49646-9553
US

IV. Provider business mailing address

8680 S LAKEVIEW RD
TRAVERSE CITY MI
49684-7699
US

V. Phone/Fax

Practice location:
  • Phone: 231-258-5133
  • Fax:
Mailing address:
  • Phone: 231-620-7445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: