Provider Demographics
NPI:1881579167
Name:VAN WYK, JACOB S (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:S
Last Name:VAN WYK
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 1:4801 W 81ST ST STE 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1111
Mailing Address - Country:US
Mailing Address - Phone:952-345-3000
Mailing Address - Fax:
Practice Address - Street 1:4801 W 81ST ST STE 112
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1111
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:952-345-6789
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist