Provider Demographics
NPI:1134989460
Name:SPEECHLEY, JACOB RONALD (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RONALD
Last Name:SPEECHLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15240 OLYMPIC LN
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-9166
Mailing Address - Country:US
Mailing Address - Phone:815-955-1533
Mailing Address - Fax:
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-848-8152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program