Provider Demographics
NPI:1881294973
Name:SORUM, JACOB P
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:P
Last Name:SORUM
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 1:30690 HIGHWAY 72
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80403-8467
Mailing Address - Country:US
Mailing Address - Phone:605-641-6231
Mailing Address - Fax:
Practice Address - Street 1:30690 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-8467
Practice Address - Country:US
Practice Address - Phone:605-641-6231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant