Provider Demographics
NPI:1497197016
Name:BAL, JACOB DANIEL (SLP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:BAL
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 TRAIL AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4934
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:301-668-2202
Practice Address - Street 1:626 TRAIL AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4934
Practice Address - Country:US
Practice Address - Phone:301-662-1997
Practice Address - Fax:301-668-2202
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006812235Z00000X
WVSLP-1452235Z00000X
MD07324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD07324OtherSTATE OF MARYLAND
WVSLP-1452OtherWEST VIRGINIA BOARDNOF EXAMINERS
VA2202006812OtherCOMMONWEALTH OF VIRGINIA