MEDICARE: JAKE DALTON PARLER DPT, PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11618	SC

General Provider Information

NPI Number	:	1134837578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKE DALTON PARLER DPT, PT

Provider Business Mailing Address
First Line	:	105 OLD CARRIAGE LN
Second Line	:
City	:	BARNWELL
State	:	SC
Zip	:	29812-8061
Country	:	US
Telephone Number	:	803-671-1908
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 FOREST ACRES
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204
Country	:	US
Telephone Number	:	803-764-2363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2022
Last Update Date	:	11/14/2022

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