Provider Demographics
NPI:1962910463
Name:JELMINI, JACOB D (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:JELMINI
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E MAIN ST APT 901
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1333
Mailing Address - Country:US
Mailing Address - Phone:310-426-0188
Mailing Address - Fax:
Practice Address - Street 1:720 SPORTS CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0001
Practice Address - Country:US
Practice Address - Phone:310-426-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
20000351302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program