Provider Demographics
NPI:1134862881
Name:SHILLING, JACOB ANTHONY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANTHONY
Last Name:SHILLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 GREEN TREE CT
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6106
Mailing Address - Country:US
Mailing Address - Phone:443-610-4909
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR STE 155
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1591
Practice Address - Country:US
Practice Address - Phone:301-260-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD29154225100000X
VA2305215328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program