Provider Demographics
NPI:1801549035
Name:WALDECKER, JACOB VERNON
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:VERNON
Last Name:WALDECKER
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 1:14651 HORIZON BLVD
Mailing Address - Street 2:
Mailing Address - City:HORIZON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79928-8639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14651 HORIZON BLVD
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-8639
Practice Address - Country:US
Practice Address - Phone:270-823-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT82102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer