MEDICARE: JAROD WEAVER PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	05012096A	IN
2	225100000X	Physical Therapist	PT016434	OH

General Provider Information

NPI Number	:	1073056867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAROD WEAVER PT

Provider Business Mailing Address
First Line	:	22 NW 11TH ST
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-2818
Country	:	US
Telephone Number	:	937-681-4406
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 NW 11TH ST
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-2818
Country	:	US
Telephone Number	:	937-681-4406
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2016
Last Update Date	:	02/20/2019

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