Provider Demographics
NPI:1568723518
Name:WESTERBERG, JAKE WILLIAM
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:WILLIAM
Last Name:WESTERBERG
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:9812 SLIDE RD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5781
Practice Address - Country:US
Practice Address - Phone:806-725-8690
Practice Address - Fax:806-725-8691
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1769208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program