Provider Demographics
NPI:1043941628
Name:WRIGHT, JACOB TYLER (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:TYLER
Last Name:WRIGHT
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 1:1217 TREVINO DR NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-5843
Mailing Address - Country:US
Mailing Address - Phone:540-597-3091
Mailing Address - Fax:
Practice Address - Street 1:29 CEDAR RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083
Practice Address - Country:US
Practice Address - Phone:304-645-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215038261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy