Provider Demographics
NPI:1801608567
Name:JACOBS, JACOB TYLER (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:TYLER
Last Name:JACOBS
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 1:11816 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64134-3723
Mailing Address - Country:US
Mailing Address - Phone:816-080-8722
Mailing Address - Fax:
Practice Address - Street 1:9201 W 133RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-4751
Practice Address - Country:US
Practice Address - Phone:816-808-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist