MEDICARE: MR. JACOB HOGAN SANDERS MA, CCC-SLP

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	235Z00000X	Speech-Language Pathologist	146010063	IL
2	235Z00000X	Speech-Language Pathologist	113349	TX

General Provider Information

NPI Number	:	1205130242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB HOGAN SANDERS MA, CCC-SLP

Provider Business Mailing Address
First Line	:	8161 RUSE SPRINGS LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-5444
Country	:	US
Telephone Number	:	847-567-5139
Fax Number	:

Provider Business Practice Location Address
First Line	:	8161 RUSE SPRINGS LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-5444
Country	:	US
Telephone Number	:	847-567-5139
Fax Number	:

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

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	03/24/2022

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