Provider Demographics
NPI:1629318514
Name:POPOOLA, JACOB O
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:O
Last Name:POPOOLA
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 1:7015 BONNIE DR
Mailing Address - Street 2:APT. 58
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2857
Mailing Address - Country:US
Mailing Address - Phone:240-286-2177
Mailing Address - Fax:
Practice Address - Street 1:7015 BONNIE DR
Practice Address - Street 2:APT. 58
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2857
Practice Address - Country:US
Practice Address - Phone:240-286-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker