MEDICARE: JACOB TANNER DPT

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	2305211376	VA

General Provider Information

NPI Number	:	1245755875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB TANNER DPT

Provider Business Mailing Address
First Line	:	1111 CORPORATE PARK DR STE B
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-2279
Country	:	US
Telephone Number	:	434-525-4851
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 CORPORATE PARK DR STE B
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-2279
Country	:	US
Telephone Number	:	434-525-4851
Fax Number	:

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

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	07/21/2022

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