Provider Demographics
NPI:1568008431
Name:RICKARD, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RICKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PLEASANT GROVE FWY APT 301
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2244
Mailing Address - Country:US
Mailing Address - Phone:901-337-7237
Mailing Address - Fax:
Practice Address - Street 1:2805 CHARLES BRYAN RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4756
Practice Address - Country:US
Practice Address - Phone:901-386-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6010225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist