Provider Demographics
NPI:1639711559
Name:CLEVENGER, JACOB (OTR/L)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 VINTAGE HILLS DR APT A
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-4780
Mailing Address - Country:US
Mailing Address - Phone:931-619-1564
Mailing Address - Fax:
Practice Address - Street 1:1710 KY-121 SUITE K
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071
Practice Address - Country:US
Practice Address - Phone:270-767-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2023-01-09
Deactivation Date:2022-12-29
Deactivation Code:
Reactivation Date:2023-01-04
Provider Licenses
StateLicense IDTaxonomies
KY280029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist