Provider Demographics
NPI:1851176317
Name:SIDLE, JACOB ANDREW (PTA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:SIDLE
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 1:759 HAMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1813
Mailing Address - Country:US
Mailing Address - Phone:440-334-6873
Mailing Address - Fax:
Practice Address - Street 1:2550 S STATE ROUTE 100
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-9356
Practice Address - Country:US
Practice Address - Phone:419-447-7203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013550225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant