Provider Demographics
NPI:1538046222
Name:PAPANICOLAS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PAPANICOLAS
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 1:650 N HASKELL ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2592
Mailing Address - Country:US
Mailing Address - Phone:707-396-2759
Mailing Address - Fax:
Practice Address - Street 1:402 SE G ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3066
Practice Address - Country:US
Practice Address - Phone:541-476-1583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-16
Last Update Date:2025-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist