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General NPI Number Information
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NPI Number | 1568138576
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Entity Type | Individual
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Provider Name | JACOB E TODD PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/19/2021
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 1435 S MAPLE GROVE RD
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City | BOISE
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State | ID
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Zip | 83709-1611
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Country | US
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Telephone | 208-332-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 1714 2ND ST N
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City | FARGO
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State | ND
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Zip | 58102-2328
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Country | US
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Telephone | 701-403-9853
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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 | PT-7512
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License Number State |
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