Provider Demographics
NPI:1033402474
Name:DEPEW, JACOB TYLER (MS, ATC, LAT, PES)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:TYLER
Last Name:DEPEW
Suffix:
Gender:M
Credentials:MS, ATC, LAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 MONTLIEU AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4221
Mailing Address - Country:US
Mailing Address - Phone:336-841-4500
Mailing Address - Fax:336-841-9182
Practice Address - Street 1:833 MONTLIEU AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4221
Practice Address - Country:US
Practice Address - Phone:336-841-4500
Practice Address - Fax:336-841-9182
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer