Provider Demographics
NPI:1902548225
Name:GRAVENKAMP, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GRAVENKAMP
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 1:21345 CLEARFIELD CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3917
Mailing Address - Country:US
Mailing Address - Phone:262-312-0671
Mailing Address - Fax:
Practice Address - Street 1:21345 CLEARFIELD CT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3917
Practice Address - Country:US
Practice Address - Phone:262-312-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist