Provider Demographics
NPI:1811404171
Name:PROFFER, JACOB RILEY (DAT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RILEY
Last Name:PROFFER
Suffix:
Gender:M
Credentials:DAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 LOBDELL AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4610
Mailing Address - Country:US
Mailing Address - Phone:225-924-2157
Mailing Address - Fax:225-924-5674
Practice Address - Street 1:12400 BURBANK DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-924-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003343A2255A2300X
FLAL62502255A2300X
LA3375242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer