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General NPI Number Information
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NPI Number | 1720775067
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Entity Type | Individual
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Provider Name | JACOB LEGAN DAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 04/18/2023
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 2401 ONTARIO ST
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City | CLEVELAND
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State | OH
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Zip | 44115-4003
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Country | US
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Telephone | 910-548-2993
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 N KOHLER RD
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City | ORRVILLE
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State | OH
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Zip | 44667-9634
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Country | US
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Telephone | 910-548-2993
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT004075
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License Number State | OH
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