Provider Demographics
NPI:1033870092
Name:SHARP, JACOB WAYNE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WAYNE
Last Name:SHARP
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 1:211 W HARDANGER GATE
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:IL
Mailing Address - Zip Code:60530-9720
Mailing Address - Country:US
Mailing Address - Phone:309-337-0897
Mailing Address - Fax:
Practice Address - Street 1:211 W HARDANGER GATE
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:IL
Practice Address - Zip Code:60530-9720
Practice Address - Country:US
Practice Address - Phone:309-337-0897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116231225100000X
AK207911225100000X
IL160006878225200000X
IL070026829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant