Provider Demographics
NPI:1215551551
Name:CALLAHAN, JACOB RILEY (MS, ATC, CES)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RILEY
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:MS, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 MISSION VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3214
Mailing Address - Country:US
Mailing Address - Phone:619-846-0428
Mailing Address - Fax:
Practice Address - Street 1:5302 55TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:619-594-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer