Healthcare Provider Details

I. General information

NPI: 1831723634
Provider Name (Legal Business Name): JACOB GILBERT OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 RAY C HUNT DR
CHARLOTTESVILLE VA
22903-2981
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-244-2015
  • Fax: 434-434-0320
Mailing address:
  • Phone: 434-295-1000
  • Fax: 434-972-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119007670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: