Provider Demographics
NPI:1609486208
Name:LENTHALL, JACOB J (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:LENTHALL
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 GLENNIE ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3917
Mailing Address - Country:US
Mailing Address - Phone:508-791-8740
Mailing Address - Fax:508-752-3716
Practice Address - Street 1:30 GLENNIE ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3917
Practice Address - Country:US
Practice Address - Phone:508-791-8740
Practice Address - Fax:508-752-3716
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA24997OtherSTATE LICENSE