Provider Demographics
NPI:1053937615
Name:BLONG, JACOB THOMAS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:BLONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-4049
Mailing Address - Country:US
Mailing Address - Phone:218-834-2586
Mailing Address - Fax:
Practice Address - Street 1:1451 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-4049
Practice Address - Country:US
Practice Address - Phone:218-834-2586
Practice Address - Fax:218-834-2587
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist