Provider Demographics
NPI:1649095670
Name:MAYES, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAYES
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 1:27 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-1734
Mailing Address - Country:US
Mailing Address - Phone:717-242-1428
Mailing Address - Fax:717-248-1937
Practice Address - Street 1:27 N BROWN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1734
Practice Address - Country:US
Practice Address - Phone:717-242-1428
Practice Address - Fax:717-248-1937
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20525175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist