Provider Demographics
NPI:1164037941
Name:BUCHANAN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 BAYOU VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-5006
Mailing Address - Country:US
Mailing Address - Phone:601-650-6286
Mailing Address - Fax:
Practice Address - Street 1:924 STATE HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9004
Practice Address - Country:US
Practice Address - Phone:601-650-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant