=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508411489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB CLAYTON WELLER DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2019
-----------------------------------------------------
Last Update Date | 06/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16528 E DESMET CT STE 1600B
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-944-8958
-----------------------------------------------------
Fax | 509-944-8959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N HOWARD ST # 6577
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99201-0508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-289-4117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 61208137
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------