Provider Demographics
NPI:1548832090
Name:GREDVIG, JACOB (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GREDVIG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 W HERSEY ST UNIT 16
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1789
Mailing Address - Country:US
Mailing Address - Phone:952-807-4884
Mailing Address - Fax:
Practice Address - Street 1:370 E HERSEY ST STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2325
Practice Address - Country:US
Practice Address - Phone:541-482-6360
Practice Address - Fax:541-482-6801
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty