Provider Demographics
NPI:1477744373
Name:GOMOKE, JACOB AVERY (PT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:AVERY
Last Name:GOMOKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 CALVERTON WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-4463
Mailing Address - Country:US
Mailing Address - Phone:757-484-9320
Mailing Address - Fax:
Practice Address - Street 1:5818 HARBOUR VIEW BLVD # D
Practice Address - Street 2:SUITE 150
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-638-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist