Provider Demographics
NPI:1700568375
Name:PUCKETT, JAKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-7986
Mailing Address - Country:US
Mailing Address - Phone:502-225-9981
Mailing Address - Fax:
Practice Address - Street 1:1212 MARKET ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-7986
Practice Address - Country:US
Practice Address - Phone:502-225-9981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist