Provider Demographics
NPI:1659893907
Name:JACOBS, JEREMY DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713-1325
Mailing Address - Country:US
Mailing Address - Phone:740-425-4350
Mailing Address - Fax:
Practice Address - Street 1:302 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1325
Practice Address - Country:US
Practice Address - Phone:740-425-4350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06499225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty