Provider Demographics
NPI:1972000800
Name:DEPOLO, JACOB THOMAS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:DEPOLO
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 1:1924 ALCOA HWY # U-107
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:865-305-8685
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HWY # U-107
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program