Healthcare Provider Details

I. General information

NPI: 1427539055
Provider Name (Legal Business Name): MR. JACOB MAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1871 WELLS RD STE 10
ORANGE PARK FL
32073-2350
US

IV. Provider business mailing address

4006 3RD ST S
JACKSONVILLE BEACH FL
32250-5848
US

V. Phone/Fax

Practice location:
  • Phone: 904-579-4814
  • Fax: 904-247-4328
Mailing address:
  • Phone: 904-247-4327
  • Fax: 904-247-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5362
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: