Provider Demographics
NPI:1114969060
Name:CHANEY, JACOB DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:CHANEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:1327 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4443
Practice Address - Country:US
Practice Address - Phone:903-510-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183908603Medicaid
TX75-2616977-042OtherTRICARE
TX183908601Medicaid
TX776514OtherMEDICARE
TX8Y9987OtherBCBS OF TEXAS
TX8Y9987OtherBCBS OF TEXAS
TX183908601Medicaid