Provider Demographics
NPI:1174093736
Name:DAMCOTT, JACOB TYLER (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:TYLER
Last Name:DAMCOTT
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 1:9712 NE SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14775
Mailing Address - Country:US
Mailing Address - Phone:716-499-0228
Mailing Address - Fax:716-793-2257
Practice Address - Street 1:189 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NY
Practice Address - Zip Code:14787
Practice Address - Country:US
Practice Address - Phone:716-793-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042593-12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic