Provider Demographics
NPI:1770364150
Name:HACKER, JACOB LOGAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LOGAN
Last Name:HACKER
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 1:4301 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4472
Mailing Address - Country:US
Mailing Address - Phone:580-558-8416
Mailing Address - Fax:
Practice Address - Street 1:BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH)
Practice Address - Street 2:UNIT 15245 APO, AP 96271
Practice Address - City:CAMP HUMPHREYS
Practice Address - State:GYEONGGI-DO
Practice Address - Zip Code:96271
Practice Address - Country:KP
Practice Address - Phone:513-416-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1384176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist