Provider Demographics
NPI:1194894980
Name:PATTENGILL, JACOB CHANNING (PT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CHANNING
Last Name:PATTENGILL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1908 SUE ANNE TRAIL
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701
Mailing Address - Country:US
Mailing Address - Phone:573-334-7657
Mailing Address - Fax:
Practice Address - Street 1:240 S MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4918
Practice Address - Country:US
Practice Address - Phone:573-334-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002029012OtherLICENSE#