Provider Demographics
NPI:1730671199
Name:FORSYTHE, JACOB (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6016 GRAY GATE LN APT C
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4024
Mailing Address - Country:US
Mailing Address - Phone:216-973-3019
Mailing Address - Fax:
Practice Address - Street 1:5900 QUAIL HOLLOW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-5005
Practice Address - Country:US
Practice Address - Phone:704-716-6881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist