Provider Demographics
NPI:1437311081
Name:MAYBERRY, JACOB (AS-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:AS-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BLUE WATER DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-4336
Mailing Address - Country:US
Mailing Address - Phone:940-683-8078
Mailing Address - Fax:940-683-8078
Practice Address - Street 1:104 BLUE WATER DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-4336
Practice Address - Country:US
Practice Address - Phone:940-683-8078
Practice Address - Fax:940-683-8078
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTC08-0326A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist