Provider Demographics
NPI:1972231223
Name:KLOCK, JACOB (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KLOCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7277 SMITHS MILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8195
Mailing Address - Country:US
Mailing Address - Phone:614-304-2123
Mailing Address - Fax:614-304-2111
Practice Address - Street 1:7277 SMITHS MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8195
Practice Address - Country:US
Practice Address - Phone:614-304-2123
Practice Address - Fax:614-304-2111
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist