Healthcare Provider Details

I. General information

NPI: 1932691276
Provider Name (Legal Business Name): JACOB WAYNE SCHICK CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 06/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

1315 W ST NW APT 446
WASHINGTON DC
20009-6853
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-2025
  • Fax:
Mailing address:
  • Phone: 614-315-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number99
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: