Provider Demographics
NPI:1205311651
Name:HURLBURT, JACOB RYAN (PTA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:RYAN
Last Name:HURLBURT
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 1:1123 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-1807
Mailing Address - Country:US
Mailing Address - Phone:715-495-4625
Mailing Address - Fax:
Practice Address - Street 1:6908 N SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-3942
Practice Address - Country:US
Practice Address - Phone:414-352-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2839-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant