Provider Demographics
NPI:1558886085
Name:TEIXEIRA, JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TEIXEIRA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 COUNTY ST
Mailing Address - Street 2:
Mailing Address - City:DIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02715-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2503
Practice Address - Country:US
Practice Address - Phone:508-548-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MAPA9070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000029219OtherATHLETIC TRAINING BOARD OF CERTIFICATION