Provider Demographics
NPI:1851089403
Name:STEPHERSON, JACOB REUBEN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:REUBEN
Last Name:STEPHERSON
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 1:535 TOM SAWYER LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-1029
Mailing Address - Country:US
Mailing Address - Phone:850-316-5041
Mailing Address - Fax:
Practice Address - Street 1:535 TOM SAWYER LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-1029
Practice Address - Country:US
Practice Address - Phone:850-316-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program