Provider Demographics
NPI:1124688585
Name:BURTCH, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BURTCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5129
Mailing Address - Country:US
Mailing Address - Phone:325-223-6300
Mailing Address - Fax:907-376-2365
Practice Address - Street 1:3001 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5129
Practice Address - Country:US
Practice Address - Phone:325-223-6300
Practice Address - Fax:325-793-3587
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK145134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14493767OtherCOMMERCIAL INSURANCE
TX14493767Medicaid