Provider Demographics
NPI:1649422155
Name:BLAINE, JACOB E (MS, PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:BLAINE
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3342
Mailing Address - Country:US
Mailing Address - Phone:607-277-8020
Mailing Address - Fax:607-277-7961
Practice Address - Street 1:1001 W SENECA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3342
Practice Address - Country:US
Practice Address - Phone:607-277-8020
Practice Address - Fax:607-277-7961
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022013-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist