Provider Demographics
NPI:1447999529
Name:MATTIA, JACOB MATTHEW (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:MATTIA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54313 SCARBORO WAY
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1287
Mailing Address - Country:US
Mailing Address - Phone:248-321-7249
Mailing Address - Fax:
Practice Address - Street 1:395 N GROESBECK HWY STE L
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1561
Practice Address - Country:US
Practice Address - Phone:586-630-0474
Practice Address - Fax:586-630-0476
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501302104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist