Provider Demographics
NPI:1124123872
Name:IBEY, JACOB DAVID (ATC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DAVID
Last Name:IBEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 GIDDINGS AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3702
Mailing Address - Country:US
Mailing Address - Phone:860-687-1459
Mailing Address - Fax:
Practice Address - Street 1:3 WEYMOUTH RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-763-7625
Practice Address - Fax:860-272-2912
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer