Provider Demographics
NPI:1417428350
Name:DAVIS, JACOB RYAN (MS, OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:RYAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 RADIO PARK DR STE 1
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2998
Mailing Address - Country:US
Mailing Address - Phone:937-478-2350
Mailing Address - Fax:859-625-5987
Practice Address - Street 1:350 RADIO PARK DR STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-625-5986
Practice Address - Fax:859-625-5987
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244835225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist