Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 05012967A | IN |
NPI | 1528525920 |
---|---|
Provider Name | Jacob Steven Laverman |
First Address | Indianapolis, IN 46214-1267 |
Second Address | Bloomington, IN 47408-1590 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2019 |
Last Update Date | 10/08/2020 |