MEDICARE: JACOB DAVIS

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	302R00000X	Health Maintenance Organization	5559	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932672979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB DAVIS

Provider Business Mailing Address
First Line	:	606 COLONIAL DR STE B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6535
Country	:	US
Telephone Number	:	225-406-7670
Fax Number	:

Provider Business Practice Location Address
First Line	:	606 COLONIAL DR STE B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-6535
Country	:	US
Telephone Number	:	225-406-7670
Fax Number	:

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

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	01/02/2019

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Directions to “ JACOB DAVIS ” Practice Location

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