Healthcare Provider Details

I. General information

NPI: 1881352516
Provider Name (Legal Business Name): JACOB RANDOLPH SHATTUCK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAGLE LAKE TRL
ROME GA
30165-2207
US

IV. Provider business mailing address

10133 SHERRILL BVLD UNIT 200
KNOXVILLE TN
37932
US

V. Phone/Fax

Practice location:
  • Phone: 706-368-9955
  • Fax:
Mailing address:
  • Phone: 865-531-2204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2136779
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP008628A
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: