Provider Demographics
NPI:1417589268
Name:LEZON, JACOB MICHAEL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:LEZON
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 1:30501 NEVINS ST.
Mailing Address - Street 2:
Mailing Address - City:FT. RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-8071
Mailing Address - Fax:
Practice Address - Street 1:30501 NEVINS ST.
Practice Address - Street 2:
Practice Address - City:FT. RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-8071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3497387146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic