Provider Demographics
NPI:1265186258
Name:DEETER, JACOB AARON (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AARON
Last Name:DEETER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 CENTENNIAL HILLS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3265
Mailing Address - Country:US
Mailing Address - Phone:307-472-8871
Mailing Address - Fax:307-265-9040
Practice Address - Street 1:4140 CENTENNIAL HILLS BLVD STE B
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3265
Practice Address - Country:US
Practice Address - Phone:307-472-8871
Practice Address - Fax:307-265-9040
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-2333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist