Provider Demographics
NPI:1013647957
Name:ROMBOLD, JACOB (PTA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ROMBOLD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1384
Mailing Address - Country:US
Mailing Address - Phone:765-919-4444
Mailing Address - Fax:574-753-1589
Practice Address - Street 1:751 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1384
Practice Address - Country:US
Practice Address - Phone:765-919-4444
Practice Address - Fax:574-753-1589
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005234A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant