Provider Demographics
NPI:1649719493
Name:HUTCHINGS, JACOB
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:HUTCHINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:HUTCHINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:13 HILLCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5255
Mailing Address - Country:US
Mailing Address - Phone:314-306-2468
Mailing Address - Fax:
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD110231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program