Provider Demographics
NPI:1487107231
Name:POWELL, JACOB ROBERT (ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:POWELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2150
Mailing Address - Country:US
Mailing Address - Phone:781-913-6120
Mailing Address - Fax:
Practice Address - Street 1:70 FULLER AVE
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-2150
Practice Address - Country:US
Practice Address - Phone:781-913-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer