Provider Demographics
NPI:1891363347
Name:MOSELEY, JACOB TYRELL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TYRELL
Last Name:MOSELEY
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 1:400 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:TX
Mailing Address - Zip Code:76531-1518
Mailing Address - Country:US
Mailing Address - Phone:254-386-1550
Mailing Address - Fax:254-386-1646
Practice Address - Street 1:400 N BROWN ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:TX
Practice Address - Zip Code:76531-1518
Practice Address - Country:US
Practice Address - Phone:254-386-1550
Practice Address - Fax:254-386-1646
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1287222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist