Provider Demographics
NPI:1396505335
Name:PREVOST, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PREVOST
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 1:2609 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2724
Mailing Address - Country:US
Mailing Address - Phone:810-941-9005
Mailing Address - Fax:
Practice Address - Street 1:6117 OLD COUNTRY LN
Practice Address - Street 2:
Practice Address - City:BURTCHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48059-2415
Practice Address - Country:US
Practice Address - Phone:810-388-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider