Provider Demographics
NPI:1629625363
Name:WOODARD, JACOB DANIEL (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:WOODARD
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 PIG BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BRUSH CREEK
Mailing Address - State:TN
Mailing Address - Zip Code:38547-5116
Mailing Address - Country:US
Mailing Address - Phone:615-489-0621
Mailing Address - Fax:
Practice Address - Street 1:1411 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-444-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAT00000021132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer