Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 005251 | KY |
NPI | 1245474774 |
---|---|
Provider Name | Mr. Jack Jacobs |
First Address | Louisville, KY 40220-3576 |
Second Address | Louisville, KY 40205-1803 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2009 |
Last Update Date | 28/04/2009 |