Provider Demographics
NPI:1588937130
Name:LAME, JACOB L (PTA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:L
Last Name:LAME
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
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Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:STE. 100
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:971-206-5203
Practice Address - Street 1:909 RESERVE ST.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-343-7717
Practice Address - Fax:208-336-4629
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPTA-370225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant