Provider Demographics
NPI:1285202465
Name:SANNER, JAKE ADAM (PT, DPT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ADAM
Last Name:SANNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 CRAIN HWY S STE 110
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4086
Mailing Address - Country:US
Mailing Address - Phone:410-762-2124
Mailing Address - Fax:
Practice Address - Street 1:1406 CRAIN HWY S STE 110
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4086
Practice Address - Country:US
Practice Address - Phone:410-762-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist