Provider Demographics
NPI:1699354092
Name:HUSTON-CRAVENS, JACOB BLAIR (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BLAIR
Last Name:HUSTON-CRAVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:BLAIR
Other - Last Name:HUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-3555
Practice Address - Fax:210-702-4239
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU9970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program