Provider Demographics
NPI:1184950784
Name:JACOB MAYBERRY ASSISTING SERVICES
Entity type:Organization
Organization Name:JACOB MAYBERRY ASSISTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:CFA
Authorized Official - Phone:281-463-6309
Mailing Address - Street 1:PO BOX 2201
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6158
Mailing Address - Country:US
Mailing Address - Phone:281-463-6309
Mailing Address - Fax:281-463-6835
Practice Address - Street 1:104 BLUE WATER DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-4336
Practice Address - Country:US
Practice Address - Phone:281-463-6309
Practice Address - Fax:281-463-6835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC080326A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty