Healthcare Provider Details

I. General information

NPI: 1710761069
Provider Name (Legal Business Name): JACOB CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

IV. Provider business mailing address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-2273
  • Fax:
Mailing address:
  • Phone: 762-408-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12528
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: