Provider Demographics
NPI:1205502762
Name:GAMBLE, JACOB RANDEL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RANDEL
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13559 NW 1ST LN
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3473
Mailing Address - Country:US
Mailing Address - Phone:352-558-3189
Mailing Address - Fax:352-226-8744
Practice Address - Street 1:13559 NW 1ST LN
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-3473
Practice Address - Country:US
Practice Address - Phone:325-558-3189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29237225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant