Provider Demographics
NPI:1639954134
Name:SAMPSON, JACOB (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SAMPSON
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 1:9082 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7780
Mailing Address - Country:US
Mailing Address - Phone:131-752-4857
Mailing Address - Fax:
Practice Address - Street 1:5641 CRAWFORDSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3718
Practice Address - Country:US
Practice Address - Phone:317-524-8570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05015279A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist