Provider Demographics
NPI:1407539976
Name:SMITH, JACOB TYLER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TYLER
Last Name:SMITH
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 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:334-231-5364
Mailing Address - Fax:334-513-7138
Practice Address - Street 1:4108 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2604
Practice Address - Country:US
Practice Address - Phone:817-238-9295
Practice Address - Fax:817-238-9299
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1381121225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist