Provider Demographics
NPI:1245931153
Name:CREED, JAKOB
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:
Last Name:CREED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15338 CHESHUNT LN
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-2202
Mailing Address - Country:US
Mailing Address - Phone:832-472-1645
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVE
Practice Address - Street 2:1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:832-472-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians