Healthcare Provider Details

I. General information

NPI: 1053299016
Provider Name (Legal Business Name): COURTNEY JACOB
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SW CROWELL WAY STE 100
BEND OR
97702-3429
US

IV. Provider business mailing address

62909 NASU PARK LOOP
BEND OR
97701-9775
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-8769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number455975
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: