Provider Demographics
NPI:1790373827
Name:HERRING, JACOB LEE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:HERRING
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 LAKE RIDGE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-1706
Mailing Address - Country:US
Mailing Address - Phone:214-278-5000
Mailing Address - Fax:214-278-5001
Practice Address - Street 1:4560 LAKE RIDGE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-1706
Practice Address - Country:US
Practice Address - Phone:214-278-5000
Practice Address - Fax:214-278-5001
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT71522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer