Provider Demographics
NPI:1598061715
Name:BOYD, JACOB R
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:R
Last Name:BOYD
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 1:2560 MONTESSOURI ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3061
Mailing Address - Country:US
Mailing Address - Phone:702-478-8400
Mailing Address - Fax:702-478-8500
Practice Address - Street 1:2560 MONTESSOURI ST
Practice Address - Street 2:SUITE 207
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3061
Practice Address - Country:US
Practice Address - Phone:702-478-8400
Practice Address - Fax:702-478-8500
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV82Medicaid
NV82OtherAMERIGROUP