Basic Information
| Provider Information | |||||||||
| NPI: | 1063816049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOWELL | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 ELDRIDGE AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723964032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | 8702088989 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 ELDRIDGE AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723964032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702088989 | ||||||||
| FaxNumber: | 8702088989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2014 | ||||||||
| LastUpdateDate: | 10/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 3890 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT 3890 | 01 | AR | PHYSICAL THERAPIST | OTHER |