Provider Demographics
NPI:1639484322
Name:HYATT, JACOB R (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:HYATT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 E DESERT COVE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6710
Mailing Address - Country:US
Mailing Address - Phone:480-860-4298
Mailing Address - Fax:480-860-0356
Practice Address - Street 1:20950 N TATUM BLVD
Practice Address - Street 2:SUITE100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4200
Practice Address - Country:US
Practice Address - Phone:480-502-5510
Practice Address - Fax:480-538-4862
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8985225100000X
AZMT12341225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8985OtherPT LICENSE