Provider Demographics
NPI:1639749617
Name:FUNDERBURK, JACOB WADE (PLPC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WADE
Last Name:FUNDERBURK
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3124
Mailing Address - Country:US
Mailing Address - Phone:318-508-1301
Mailing Address - Fax:
Practice Address - Street 1:6240 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-8413
Practice Address - Country:US
Practice Address - Phone:318-562-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator