Provider Demographics
NPI:1568940237
Name:JACOB, SETH ALEX
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ALEX
Last Name:JACOB
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 1:7931 N 154TH ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7931 N 154TH ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:NE
Practice Address - Zip Code:68007-1838
Practice Address - Country:US
Practice Address - Phone:402-917-8627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer