Provider Demographics
NPI:1548815665
Name:MOYER, JACOB RICHARD (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RICHARD
Last Name:MOYER
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 1:1965 HILLHURST AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2711
Mailing Address - Country:US
Mailing Address - Phone:323-912-9166
Mailing Address - Fax:
Practice Address - Street 1:1965 HILLHURST AVE FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2711
Practice Address - Country:US
Practice Address - Phone:323-912-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist