Provider Demographics
NPI:1780214593
Name:PULLIAM, JACOB TOWNSEND
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TOWNSEND
Last Name:PULLIAM
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:PO BOX 10016
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-3216
Mailing Address - Country:US
Mailing Address - Phone:909-978-7997
Mailing Address - Fax:909-361-4726
Practice Address - Street 1:1323 W COLTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4554
Practice Address - Country:US
Practice Address - Phone:909-978-7997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27380235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist