Provider Demographics
NPI:1043791130
Name:LUCKETT, JACOB E (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 CHENAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-7479
Mailing Address - Country:US
Mailing Address - Phone:501-975-4040
Mailing Address - Fax:501-975-4043
Practice Address - Street 1:2039 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7479
Practice Address - Country:US
Practice Address - Phone:501-605-8888
Practice Address - Fax:501-605-8899
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4563225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist