Provider Demographics
NPI:1871938217
Name:PETWAY, JACOB RICHARD (DC, QME, IIE, BS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RICHARD
Last Name:PETWAY
Suffix:
Gender:M
Credentials:DC, QME, IIE, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 AZUSA ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2328
Mailing Address - Country:US
Mailing Address - Phone:530-315-5594
Mailing Address - Fax:
Practice Address - Street 1:929 AZUSA ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-2328
Practice Address - Country:US
Practice Address - Phone:530-315-5594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA32615111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician