Provider Demographics
NPI:1568857035
Name:WATERS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WATERS
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 1:4716 WILCONNA RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7657
Mailing Address - Country:US
Mailing Address - Phone:804-528-9784
Mailing Address - Fax:
Practice Address - Street 1:235 DUNLOP FARMS BLVD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1792
Practice Address - Country:US
Practice Address - Phone:804-520-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist