Provider Demographics
NPI:1669084075
Name:BOSTICK, JAKE RYAN (PT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:RYAN
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ENTERPRISE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-3241
Mailing Address - Country:US
Mailing Address - Phone:814-308-8482
Mailing Address - Fax:
Practice Address - Street 1:3075 ENTERPRISE DR STE 200
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-3241
Practice Address - Country:US
Practice Address - Phone:814-308-8482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT028863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist