Provider Demographics
NPI:1417552688
Name:GATES, JACOB D (PTA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:GATES
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 1:18 HORIZON FLATS RD
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:WA
Mailing Address - Zip Code:98862-8400
Mailing Address - Country:US
Mailing Address - Phone:360-303-4928
Mailing Address - Fax:
Practice Address - Street 1:619 W. BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-826-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160696110225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant