Provider Demographics
NPI:1245686518
Name:DEVORE, JAKOB A (LSA)
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:A
Last Name:DEVORE
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:A
Other - Last Name:DEVORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSA
Mailing Address - Street 1:5309 CORN FIELD DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-8163
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:5309 CORN FIELD DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-8163
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0880
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS142172246ZS0410X
TXSA00729246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist