MEDICARE: MR. JACOB CHANNING PATTENGILL P.T.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2002029012	OTHER	MO	LICENSE#

General Provider Information

NPI Number	:	1194894980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB CHANNING PATTENGILL P.T.

Provider Business Mailing Address
First Line	:	1908 SUE ANNE TRAIL
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701
Country	:	US
Telephone Number	:	573-334-7657
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 S MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63703-4918
Country	:	US
Telephone Number	:	573-334-6711
Fax Number	:

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	12/15/2009

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