Provider Demographics
NPI:1043854441
Name:COMSTOCK, JACOB W (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:W
Last Name:COMSTOCK
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 1:1316 N TIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-3024
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:
Practice Address - Street 1:1316 N TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-3024
Practice Address - Country:US
Practice Address - Phone:847-441-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024810225100000X
IN05013763A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist