Provider Demographics
NPI:1457016644
Name:STROUT, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STROUT
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 1:771 SOUTHBRIDGE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-1345
Mailing Address - Country:US
Mailing Address - Phone:508-987-4211
Mailing Address - Fax:
Practice Address - Street 1:387 MAIN ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MA
Practice Address - Zip Code:01540-1780
Practice Address - Country:US
Practice Address - Phone:508-987-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst