Provider Demographics
NPI:1851020309
Name:FAY, JACOB EARL
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:EARL
Last Name:FAY
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 1:3123 MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3905
Mailing Address - Country:US
Mailing Address - Phone:171-249-0770
Mailing Address - Fax:
Practice Address - Street 1:3123 MCDONALD ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3905
Practice Address - Country:US
Practice Address - Phone:171-249-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician