MEDICARE: JACOB SLOUKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-17-25405	CA

General Provider Information

NPI Number	:	1174055198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB SLOUKA

Provider Business Mailing Address
First Line	:	264 LANDIS AVE
Second Line	:	SUITE 200
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-2627
Country	:	US
Telephone Number	:	619-977-6851
Fax Number	:	619-278-0885

Provider Business Practice Location Address
First Line	:	264 LANDIS AVE
Second Line	:	SUITE 200
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-2627
Country	:	US
Telephone Number	:	619-977-6851
Fax Number	:	619-278-0885

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2017
Last Update Date	:	03/29/2017

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