Provider Demographics
NPI:1114656246
Name:JACOBS, ANTHONY B (PTA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:B
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 HOLLOWELL ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3306
Mailing Address - Country:US
Mailing Address - Phone:909-437-9767
Mailing Address - Fax:
Practice Address - Street 1:732 HOLLOWELL ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3306
Practice Address - Country:US
Practice Address - Phone:909-437-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50823225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty