Basic Information
| Provider Information | |||||||||
| NPI: | 1558716027 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PAWOL | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 VISTA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502669317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 PLEASANT ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759706 | ||||||||
| FaxNumber: | 5158759707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2016 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12274PT | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 095370 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.