Provider Demographics
NPI:1033792080
Name:POTRZEBA, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:POTRZEBA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PHEASANT LN
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12529-5410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 PHEASANT LN
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:NY
Practice Address - Zip Code:12529-5410
Practice Address - Country:US
Practice Address - Phone:518-672-7312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037873-01225100000X
MA222352251H1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman FactorsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty