Provider Demographics
NPI:1831470335
Name:TRYON, JACOB
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:TRYON
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 1:500 N BULLARD AVE
Mailing Address - Street 2:#27
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N BULLARD AVE
Practice Address - Street 2:#27
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2533
Practice Address - Country:US
Practice Address - Phone:623-986-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA72292355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant