Provider Demographics
NPI:1114554227
Name:ZAVALA, JACOB ADAM
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ADAM
Last Name:ZAVALA
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 1:1153 ASH ST STE B
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3844
Mailing Address - Country:US
Mailing Address - Phone:805-458-3659
Mailing Address - Fax:
Practice Address - Street 1:2945 MCMILLAN AVE STE 240
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6771
Practice Address - Country:US
Practice Address - Phone:805-439-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41575167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician