Provider Demographics
NPI:1245118801
Name:WALL, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WALL
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 1:57 GILDERSLEEVE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06019-3009
Mailing Address - Country:US
Mailing Address - Phone:860-806-4202
Mailing Address - Fax:
Practice Address - Street 1:240 PHELPS ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-2042
Practice Address - Country:US
Practice Address - Phone:503-873-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist