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General NPI Number Information
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NPI Number | 1366121782
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Entity Type | Individual
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Provider Name | JACOB AUGUST NOVAK PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 17110 W GREENFIELD AVE STE 7
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City | BROOKFIELD
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State | WI
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Zip | 53005-6947
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Country | US
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Telephone | 262-297-9414
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Fax |
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Provider Business Mailing Address
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Address Line | 276 LAKEVIEW DR APT 4
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City | HARTLAND
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State | WI
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Zip | 53029-1630
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Country | US
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Telephone | 734-904-3323
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1645024
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License Number State | WI
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