Provider Demographics
NPI:1831503002
Name:KOONTZ, JACOB AVERY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AVERY
Last Name:KOONTZ
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 1:8151 N CEDAR AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2285
Mailing Address - Country:US
Mailing Address - Phone:412-651-8336
Mailing Address - Fax:
Practice Address - Street 1:456 S MADERA AVE
Practice Address - Street 2:
Practice Address - City:KERMAN
Practice Address - State:CA
Practice Address - Zip Code:93630-1538
Practice Address - Country:US
Practice Address - Phone:559-846-7115
Practice Address - Fax:559-846-9756
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist