Provider Demographics
NPI:1235438615
Name:HEABERLIN, JACOB GLENN (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GLENN
Last Name:HEABERLIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 FORUM DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2448
Mailing Address - Country:US
Mailing Address - Phone:573-426-4300
Mailing Address - Fax:573-426-2009
Practice Address - Street 1:1311 FORUM DR STE A
Practice Address - Street 2:SUITE A
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2519
Practice Address - Country:US
Practice Address - Phone:573-426-4300
Practice Address - Fax:573-426-2009
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011003626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor