Healthcare Provider Details

I. General information

NPI: 1962426858
Provider Name (Legal Business Name): JACOB THORP PT, DHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 STANTONSBURG RD
GREENVILLE NC
27834-7534
US

IV. Provider business mailing address

600 MOYE BLVD EAST CAROLINA UNIVERSITY; PT DEPARTMENT
GREENVILLE NC
27834
US

V. Phone/Fax

Practice location:
  • Phone: 252-695-6322
  • Fax: 252-695-6321
Mailing address:
  • Phone: 252-744-6237
  • Fax: 252-744-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number11518
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11518
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: