Healthcare Provider Details

I. General information

NPI: 1205311651
Provider Name (Legal Business Name): JACOB RYAN HURLBURT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6908 N SANTA MONICA BLVD
MILWAUKEE WI
53217-3942
US

IV. Provider business mailing address

1123 6TH AVE
GRAFTON WI
53024-1807
US

V. Phone/Fax

Practice location:
  • Phone: 414-352-2082
  • Fax:
Mailing address:
  • Phone: 715-495-4625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2839-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: