Provider Demographics
NPI:1760851075
Name:KEAN, JACOB (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KEAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 CHIPETA WAY
Mailing Address - Street 2:WILLIAMS BUILDING, RM 1N490
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-213-3751
Mailing Address - Fax:
Practice Address - Street 1:295 CHIPETA WAY
Practice Address - Street 2:WILLIAMS BUILDING, RM 1N490
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-213-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003878A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist