Provider Demographics
NPI:1346659752
Name:BOWEN, JACOB (PTA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:BOWEN
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 1:853 COLUMBIA AVE APT WEST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4305
Mailing Address - Country:US
Mailing Address - Phone:260-582-1399
Mailing Address - Fax:
Practice Address - Street 1:1955 VERNON ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-4026
Practice Address - Country:US
Practice Address - Phone:260-563-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004452A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant