Provider Demographics
NPI:1205130242
Name:SANDERS, JACOB HOGAN (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:HOGAN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8161 RUSE SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-5444
Mailing Address - Country:US
Mailing Address - Phone:847-567-5139
Mailing Address - Fax:
Practice Address - Street 1:8161 RUSE SPRINGS LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-5444
Practice Address - Country:US
Practice Address - Phone:847-567-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010063235Z00000X
TX113349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist