Provider Demographics
NPI:1194516989
Name:HAMILTON, JACOB W
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:W
Last Name:HAMILTON
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 1:652 BLADESTON DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41004-8125
Mailing Address - Country:US
Mailing Address - Phone:606-782-1088
Mailing Address - Fax:
Practice Address - Street 1:1621 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2229
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:843-353-3461
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCP044458T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist