MEDICARE: JAKE PAUL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		MI

General Provider Information

NPI Number	:	1225988959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKE PAUL

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20873 MACK AVE
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-1313
Country	:	US
Telephone Number	:	313-466-7884
Fax Number	:	313-464-0001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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Directions to “ JAKE PAUL ” Practice Location

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