Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | PT012532 | GA |
Y | 2251X0800X | Physical Therapist - Orthopedic | PT012532 | GA |
NPI | 1205380342 |
---|---|
Provider Name | Dr. Jacob Reynolds |
First Address | Atlanta, GA 30318 |
Second Address | Atlanta, GA 30318-3644 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2016 |
Last Update Date | 05/08/2016 |