Healthcare Provider Details

I. General information

NPI: 1720908817
Provider Name (Legal Business Name): JACOB WAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39514 BRADBURY LN
PRAIRIEVILLE LA
70769-4974
US

IV. Provider business mailing address

39514 BRADBURY LN
PRAIRIEVILLE LA
70769-4974
US

V. Phone/Fax

Practice location:
  • Phone: 225-290-1766
  • Fax:
Mailing address:
  • Phone: 225-290-1766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number202662
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: