Healthcare Provider Details

I. General information

NPI: 1710674783
Provider Name (Legal Business Name): JACOB ROBERT KNOWLTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 ALBERT SABIN WAY, ML 0558
CINCINNATI OH
45267-0558
US

IV. Provider business mailing address

428 BAYBERRY POINTE DR NW APT F
GRAND RAPIDS MI
49534-4643
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4748
  • Fax:
Mailing address:
  • Phone: 231-327-8231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: