Provider Demographics
NPI:1487055463
Name:WRIGHT, JACOB (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 ROY MARTIN RD STE 9
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2245
Mailing Address - Country:US
Mailing Address - Phone:423-477-1101
Mailing Address - Fax:423-477-1102
Practice Address - Street 1:110 E CENTER ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4230
Practice Address - Country:US
Practice Address - Phone:423-765-1611
Practice Address - Fax:423-765-1612
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010967Medicaid
TN6025087OtherBCBSTN