Provider Demographics
NPI:1790989945
Name:ROBERTS, JACOB BENJAMIN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:BENJAMIN
Last Name:ROBERTS
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 1:1169 WASHBURN AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-1607
Mailing Address - Country:US
Mailing Address - Phone:208-521-7336
Mailing Address - Fax:
Practice Address - Street 1:1542 ELK CREEK DR
Practice Address - Street 2:SUITE B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8322
Practice Address - Country:US
Practice Address - Phone:208-521-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT - 2217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist