Healthcare Provider Details

I. General information

NPI: 1790466548
Provider Name (Legal Business Name): JACOB TRUE KING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 W RYAN RD
OAK CREEK WI
53154-4322
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 414-973-1550
  • Fax: 414-973-1552
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17839-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: