Provider Demographics
NPI:1760903603
Name:MAUCK, JACOB (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAUCK
Suffix:
Gender:M
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 NW GARRYANNA DR APT 3
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1389
Mailing Address - Country:US
Mailing Address - Phone:541-435-0394
Mailing Address - Fax:
Practice Address - Street 1:350 S 8TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2242
Practice Address - Country:US
Practice Address - Phone:541-259-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR016041235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist