Provider Demographics
NPI:1851900047
Name:SLANN, JACOB LOUIS
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:LOUIS
Last Name:SLANN
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 1:408 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1441
Mailing Address - Country:US
Mailing Address - Phone:864-650-0804
Mailing Address - Fax:
Practice Address - Street 1:408 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1441
Practice Address - Country:US
Practice Address - Phone:864-650-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3034692081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZCX833239112903OtherBLUE CROSS BLUE SHIELD