Provider Demographics
NPI:1942619374
Name:ANDERSON, JACOB RAY (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CIVIC CENTER BLVD STE. 502
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993
Mailing Address - Country:US
Mailing Address - Phone:530-671-7977
Mailing Address - Fax:530-671-6163
Practice Address - Street 1:1110 CIVIC CENTER BLVD STE. 502
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993
Practice Address - Country:US
Practice Address - Phone:530-671-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist