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General NPI Number Information
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NPI Number | 1477185106
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Entity Type | Individual
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Provider Name | JACOB LAWRENCE CENTRA PT, DPT, CSCS
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Gender | Male
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 10840 LITTLE PATUXENT PKWY STE 105
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City | COLUMBIA
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State | MD
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Zip | 21044-3254
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Country | US
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Telephone | 410-730-2028
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Fax |
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Provider Business Mailing Address
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Address Line | 468 GLEN MAR RD APT B4
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City | GLEN BURNIE
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State | MD
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Zip | 21061-7074
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Country | US
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Telephone |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 27852
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License Number State | MD
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