Basic Information
Provider Information | |||||||||
NPI: | 1063517340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROWAN | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 804 SERVICE RD STE A109B | ||||||||
Address2: |   | ||||||||
City: | EAST LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 488247015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5178842976 | ||||||||
FaxNumber: | 5174323928 | ||||||||
Practice Location | |||||||||
Address1: | 4660 S HAGADORN RD | ||||||||
Address2: | SUITE 500 | ||||||||
City: | EAST LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 488235376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5174326144 | ||||||||
FaxNumber: | 5174326150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 06/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 5101014827 | MI | Y |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |   |
ID Information
ID | Type | State | Issuer | Description | 4624101 | 05 | MI |   | MEDICAID | 1922043389 | 05 | MI |   | MEDICAID |