Provider Demographics
NPI:1124550959
Name:DEAN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DEAN
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 1:257 MARYSVILLE LN
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7230
Mailing Address - Country:US
Mailing Address - Phone:814-327-9507
Mailing Address - Fax:
Practice Address - Street 1:257 MARYSVILLE LN
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7230
Practice Address - Country:US
Practice Address - Phone:814-327-9507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer