MEDICARE: JACOB MICHAEL PELAK PTA

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	225200000X	Physical Therapy Assistant	5502006430	MI

General Provider Information

NPI Number	:	1285426023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MICHAEL PELAK PTA

Provider Business Mailing Address
First Line	:	6902 HIGHLAND DR E
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-8637
Country	:	US
Telephone Number	:	616-916-0286
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-8042
Country	:	US
Telephone Number	:	616-259-0408
Fax Number	:

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

Provider Enumeration Date	:	05/19/2025
Last Update Date	:	05/19/2025

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