Healthcare Provider Details

I. General information

NPI: 1073423471
Provider Name (Legal Business Name): JACOB LANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 W WASHINGTON ST STE 200
MARQUETTE MI
49855-4149
US

IV. Provider business mailing address

855 PUUMALA RD
WAKEFIELD MI
49968-9527
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-2595
  • Fax:
Mailing address:
  • Phone: 906-285-4189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501304621
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: