Provider Demographics
NPI:1366965733
Name:HARDY, JACOB (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HARDY
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 1:203 LAWSON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4249
Mailing Address - Country:US
Mailing Address - Phone:225-240-9220
Mailing Address - Fax:
Practice Address - Street 1:200 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4026
Practice Address - Country:US
Practice Address - Phone:769-798-7138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT08652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer