Provider Demographics
NPI:1598433245
Name:POORE, JACOB ADAM (CRNA)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ADAM
Last Name:POORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 HIGHLANDER MEDICS STREET
Mailing Address - Street 2:
Mailing Address - City:FT. BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79918
Mailing Address - Country:US
Mailing Address - Phone:915-569-3213
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS STREET
Practice Address - Street 2:WILLIAM BEAUMONT ARMY MEDICAL CENTER
Practice Address - City:FT. BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:915-569-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA134142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered