Provider Demographics
NPI:1831073733
Name:SOPER, JACOB (LMT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SOPER
Suffix:
Gender:X
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W WACKERLY ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 W WACKERLY ST STE 100
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2795
Practice Address - Country:US
Practice Address - Phone:989-837-5997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501016890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist