Provider Demographics
NPI:1902521206
Name:FICKEL, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FICKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5232
Mailing Address - Country:US
Mailing Address - Phone:616-990-5701
Mailing Address - Fax:
Practice Address - Street 1:1103 COLONIAL CT
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5232
Practice Address - Country:US
Practice Address - Phone:616-990-5701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant