Provider Demographics
NPI:1841941283
Name:LECLAIR, JACOB JOHN (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:LECLAIR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 MOONSTONE CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3748
Mailing Address - Country:US
Mailing Address - Phone:989-493-1807
Mailing Address - Fax:
Practice Address - Street 1:298 S NOVA RD STE E
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-0413
Practice Address - Country:US
Practice Address - Phone:386-226-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13879111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor