Provider Demographics
NPI:1417541301
Name:PAVOLIK, JACOB STEPHEN (PTA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:STEPHEN
Last Name:PAVOLIK
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 1:1109 S SCHUMAKER DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-9256
Mailing Address - Country:US
Mailing Address - Phone:443-397-5375
Mailing Address - Fax:
Practice Address - Street 1:1109 S SCHUMAKER DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-9256
Practice Address - Country:US
Practice Address - Phone:443-397-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA-4995225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant