Provider Demographics
NPI:1811235906
Name:JACOBS, MARK ANTHONY (BS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 TENNIS ST
Mailing Address - Street 2:APT D28
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-2751
Mailing Address - Country:US
Mailing Address - Phone:989-686-2462
Mailing Address - Fax:
Practice Address - Street 1:448 SIDNEY BAKER ST S
Practice Address - Street 2:SUITE 103
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5915
Practice Address - Country:US
Practice Address - Phone:989-686-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX360122355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant