Provider Demographics
NPI:1730723891
Name:BORAAS, JACOB BRADLEY (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRADLEY
Last Name:BORAAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 E 38TH ST STE 201B
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1179
Mailing Address - Country:US
Mailing Address - Phone:563-265-5494
Mailing Address - Fax:
Practice Address - Street 1:2010 E 38TH ST STE 201B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1179
Practice Address - Country:US
Practice Address - Phone:563-265-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor