Provider Demographics
NPI:1184095077
Name:GILL, JACOB LEE (SFIDC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:LEE
Last Name:GILL
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D MLG, HQ RGMT
Mailing Address - Street 2:UNIT 38404, KGAS
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96380
Mailing Address - Country:US
Mailing Address - Phone:315-637-2465
Mailing Address - Fax:
Practice Address - Street 1:3D MLG, HQ RGMT
Practice Address - Street 2:UNIT 38404, KGAS
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96380
Practice Address - Country:US
Practice Address - Phone:315-637-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-18
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman