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NPI Code Detail

MEDICARE: JACOB VAN PELT PTA

MEDICARE: JACOB VAN PELT 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
1225200000XPhysical Therapy Assistant5502005850MI

General Provider Information

NPI Number : 1912572181
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB VAN PELT PTA
Provider Business Mailing Address
First Line : 106 PROVIDER ST
Second Line :
City : GWINN
State : MI
Zip : 49841-2726
Country : US
Telephone Number : 906-458-0015
Fax Number :
Provider Business Practice Location Address
First Line : 2415 5TH AVE S
Second Line :
City : ESCANABA
State : MI
Zip : 49829-1201
Country : US
Telephone Number : 906-786-6907
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/20/2021
Last Update Date : 05/20/2021

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Directions to “ JACOB VAN PELT PTA” Practice Location

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