Provider Demographics
NPI:1235529967
Name:PROVANCE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PROVANCE
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 1:202 JACOB MURPHY LN STE 101
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-2608
Mailing Address - Country:US
Mailing Address - Phone:724-434-2720
Mailing Address - Fax:
Practice Address - Street 1:202 JACOB MURPHY LN STE 101
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2608
Practice Address - Country:US
Practice Address - Phone:724-434-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE010421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant