Provider Demographics
NPI:1902305642
Name:WHITACRE, JACOB THOMAS (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:WHITACRE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 DEBOLD KOEBEL RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:OH
Mailing Address - Zip Code:45152-8333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8400 DEBOLD KOEBEL RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:OH
Practice Address - Zip Code:45152-8333
Practice Address - Country:US
Practice Address - Phone:513-532-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 2255A2300X
KYAT18222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program