Provider Demographics
NPI:1912582362
Name:FLUELLING, JACOBY JAKE
Entity Type:Individual
Prefix:
First Name:JACOBY
Middle Name:JAKE
Last Name:FLUELLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1252
Mailing Address - Country:US
Mailing Address - Phone:856-254-6445
Mailing Address - Fax:
Practice Address - Street 1:33 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1252
Practice Address - Country:US
Practice Address - Phone:856-254-6445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00345900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QB00345900OtherPHYSICAL THERAPIST ASSISTANT