Provider Demographics
NPI:1619099942
Name:TUTTLE, JACOB LEE (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:TUTTLE
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 1:302 NORTHRIDGE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-5801
Mailing Address - Country:US
Mailing Address - Phone:580-338-4789
Mailing Address - Fax:866-999-0184
Practice Address - Street 1:302 NORTHRIDGE CIRCLE
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-5801
Practice Address - Country:US
Practice Address - Phone:580-338-4789
Practice Address - Fax:866-999-0184
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3766225100000X
CO8820225100000X
KS1104337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist