Provider Demographics
NPI:1487389052
Name:FOGARTY, JACOB CHANDLER
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:CHANDLER
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MASHBURN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-4961
Mailing Address - Country:US
Mailing Address - Phone:478-488-3359
Mailing Address - Fax:478-488-3359
Practice Address - Street 1:124 3RD ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3404
Practice Address - Country:US
Practice Address - Phone:478-662-0156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist