Basic Information
| Provider Information | |||||||||
| NPI: | 1497126866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13609 CALIFORNIA ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681545245 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13609 CALIFORNIA ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681545245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028911118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 10/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A-1177 | NM | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 14-02914 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.