Provider Demographics
NPI:1659752186
Name:AMERSON, JACOB CAGNEY (DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CAGNEY
Last Name:AMERSON
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 1:501 FOREST LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2621
Mailing Address - Country:US
Mailing Address - Phone:864-654-2001
Mailing Address - Fax:800-305-7112
Practice Address - Street 1:501 FOREST LN
Practice Address - Street 2:SUITE A
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2621
Practice Address - Country:US
Practice Address - Phone:864-654-2001
Practice Address - Fax:800-305-7112
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH2957Medicaid
SCTH2957Medicaid