Provider Demographics
NPI:1841182581
Name:MELVIN, JACOB (PTA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MELVIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10521 ROSEHAVEN ST STE LL150
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2889
Mailing Address - Country:US
Mailing Address - Phone:703-383-1616
Mailing Address - Fax:703-383-1166
Practice Address - Street 1:10521 ROSEHAVEN ST STE LL150
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2889
Practice Address - Country:US
Practice Address - Phone:703-383-1616
Practice Address - Fax:703-383-1166
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606772225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty