Healthcare Provider Details

I. General information

NPI: 1831470335
Provider Name (Legal Business Name): MR. JACOB TRYON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N BULLARD AVE #27
GOODYEAR AZ
85338-2533
US

IV. Provider business mailing address

500 N BULLARD AVE #27
GOODYEAR AZ
85338-2533
US

V. Phone/Fax

Practice location:
  • Phone: 623-986-5110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA7229
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: