Provider Demographics
NPI:1891551479
Name:REA, JACOB CHARLES (LMT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:REA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-4006
Mailing Address - Country:US
Mailing Address - Phone:210-710-7672
Mailing Address - Fax:
Practice Address - Street 1:3843 DEVON AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-4006
Practice Address - Country:US
Practice Address - Phone:210-710-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173C00000X
TXMT015749225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist