Provider Demographics
NPI:1265866768
Name:MCDERMOTT, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCDERMOTT
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 1:5595 EQUITY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2589
Mailing Address - Country:US
Mailing Address - Phone:775-322-6060
Mailing Address - Fax:775-322-6061
Practice Address - Street 1:5595 EQUITY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2589
Practice Address - Country:US
Practice Address - Phone:775-322-6060
Practice Address - Fax:775-322-6061
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health