Provider Demographics
NPI:1922469352
Name:SHULTZ, JACOB EUGENE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EUGENE
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 N WATER AVE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-1381
Mailing Address - Country:US
Mailing Address - Phone:724-977-1853
Mailing Address - Fax:
Practice Address - Street 1:1759 N WATER AVE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-1381
Practice Address - Country:US
Practice Address - Phone:724-977-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0061332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer