Healthcare Provider Details

I. General information

NPI: 1235239724
Provider Name (Legal Business Name): JACOB A LANDRUM P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W DEWITT HENRY DR STE D
BEEBE AR
72012-2102
US

IV. Provider business mailing address

PO BOX 297
BEEBE AR
72012-0297
US

V. Phone/Fax

Practice location:
  • Phone: 501-882-2260
  • Fax: 501-882-2369
Mailing address:
  • Phone: 501-882-2260
  • Fax: 501-882-2369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2923
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: