Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023541927 |
---|---|
Provider Name | Jacob Andrew Davis |
First Address | Rockford, MI 49341-9395 |
Second Address | Rockford, MI 49341-9395 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2017 |
Last Update Date | 06/04/2017 |