Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 46TR01028500 | NJ |
NPI | 1093472334 |
---|---|
Provider Name | Mr. Jacob Betkowski |
First Address | Matawan, NJ 07747-2132 |
Second Address | Matawan, NJ 07747-2132 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2021 |
Last Update Date | 22/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
46TR01028500 | LICENSE (01) | NJ |