Provider Demographics
NPI:1134505662
Name:POLLARD, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:POLLARD
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:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:IBERIA
Mailing Address - State:MO
Mailing Address - Zip Code:65486-0373
Mailing Address - Country:US
Mailing Address - Phone:573-645-6449
Mailing Address - Fax:
Practice Address - Street 1:13609 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5260
Practice Address - Country:US
Practice Address - Phone:402-891-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist