Provider Demographics
NPI:1023513991
Name:COWAN, JACOB (PTA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:COWAN
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 1:8710 AIRLANE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4102
Mailing Address - Country:US
Mailing Address - Phone:310-808-7487
Mailing Address - Fax:
Practice Address - Street 1:11710 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1503
Practice Address - Country:US
Practice Address - Phone:310-494-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant