Provider Demographics
NPI:1841527272
Name:DELVALLEY, JACOB LAYNE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LAYNE
Last Name:DELVALLEY
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:61816-0071
Mailing Address - Country:US
Mailing Address - Phone:217-637-0516
Mailing Address - Fax:
Practice Address - Street 1:1112 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5606
Practice Address - Country:US
Practice Address - Phone:217-637-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor