Provider Demographics
NPI:1720775067
Name:LEGAN, JACOB (DAT, ATC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:LEGAN
Suffix:
Gender:M
Credentials:DAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N KOHLER RD
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9634
Mailing Address - Country:US
Mailing Address - Phone:910-548-2993
Mailing Address - Fax:
Practice Address - Street 1:2401 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-4003
Practice Address - Country:US
Practice Address - Phone:910-548-2993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0040752083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine