=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396178588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB TODD THURMANN PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2013
-----------------------------------------------------
Last Update Date | 08/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3809 S 2ND ST STE B100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-447-9675
-----------------------------------------------------
Fax | 512-428-9675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3809 S 2ND ST STE B100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-447-9675
-----------------------------------------------------
Fax | 512-428-9675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 14571556
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------