Provider Demographics
NPI:1417305020
Name:GARTNER, JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GARTNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 MCFARLAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6801
Mailing Address - Country:US
Mailing Address - Phone:815-316-2100
Mailing Address - Fax:815-316-2099
Practice Address - Street 1:2902 MCFARLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6801
Practice Address - Country:US
Practice Address - Phone:815-316-6839
Practice Address - Fax:815-316-6845
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist