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General NPI Number Information
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NPI Number | 1043941628
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Entity Type | Individual
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Provider Name | JACOB TYLER WRIGHT DPT
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Gender | Male
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Dates
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Enumeration Date | 06/23/2022
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Last Update Date | 06/23/2022
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Provider Practice Location Address
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Address Line | 29 CEDAR RIDGE DRIVE
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City | DALEVILLE
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State | VA
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Zip | 24083
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Country | US
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Telephone | 304-645-2525
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Fax |
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Provider Business Mailing Address
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Address Line | 1217 TREVINO DR NE
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City | ROANOKE
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State | VA
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Zip | 24019-5843
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Country | US
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Telephone | 540-597-3091
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2305215038
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License Number State | VA
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