Provider Demographics
NPI:1891956223
Name:STOWE, JACOB RAY (OTR)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RAY
Last Name:STOWE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MEDI PARK DR STE 65
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2105
Mailing Address - Country:US
Mailing Address - Phone:806-468-7611
Mailing Address - Fax:806-468-7603
Practice Address - Street 1:1901 MEDI PARK DR STE 65
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2105
Practice Address - Country:US
Practice Address - Phone:806-468-7611
Practice Address - Fax:806-468-7603
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0217267-01Medicaid