Provider Demographics
NPI:1154128932
Name:FAY, JACOB ROBERT (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:FAY
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-0856
Mailing Address - Country:US
Mailing Address - Phone:716-667-4000
Mailing Address - Fax:716-206-7863
Practice Address - Street 1:4077 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2442
Practice Address - Country:US
Practice Address - Phone:716-667-4000
Practice Address - Fax:716-206-7863
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist