Provider Demographics
NPI:1427528637
Name:URBAN, JACOB DAVID (PTA, CSCS, FMSC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DAVID
Last Name:URBAN
Suffix:
Gender:M
Credentials:PTA, CSCS, FMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2745 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4906
Mailing Address - Country:US
Mailing Address - Phone:718-801-4618
Mailing Address - Fax:
Practice Address - Street 1:2745 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4906
Practice Address - Country:US
Practice Address - Phone:718-801-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant