Provider Demographics
NPI:1598767642
Name:JACOY, PAUL DANTE (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DANTE
Last Name:JACOY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S OAK KNOLL AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2681
Mailing Address - Country:US
Mailing Address - Phone:626-825-2621
Mailing Address - Fax:
Practice Address - Street 1:100 W WALNUT ST STE 375
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91124-1220
Practice Address - Country:US
Practice Address - Phone:323-257-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22376111NS0005X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAV296ZMedicare PIN
CADC22376Medicare ID - Type Unspecified