=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922586080
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB WALTZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2018
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14930 LAPLAISANCE RD STE 116
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48161-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-242-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14930 LAPLAISANCE RD STE 116
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48161-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010642
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------