MEDICARE: JACOB ALEXANDER TAYLOR

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	225200000X	Physical Therapy Assistant	A5114	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HUF3HZN60814420	OTHER	MD	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1932663127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ALEXANDER TAYLOR

Provider Business Mailing Address
First Line	:	3972 CHESTNUT GROVE RD
Second Line	:
City	:	SWANTON
State	:	MD
Zip	:	21561-1437
Country	:	US
Telephone Number	:	301-707-7702
Fax Number	:

Provider Business Practice Location Address
First Line	:	3972 CHESTNUT GROVE RD
Second Line	:
City	:	SWANTON
State	:	MD
Zip	:	21561-1437
Country	:	US
Telephone Number	:	301-707-7702
Fax Number	:

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

Provider Enumeration Date	:	01/22/2019
Last Update Date	:	01/22/2019

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