Healthcare Provider Details

I. General information

NPI: 1316799166
Provider Name (Legal Business Name): JACOB S MAYNES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W 24TH ST
ERIE PA
16502-2665
US

IV. Provider business mailing address

311 W 24TH ST
ERIE PA
16502-2665
US

V. Phone/Fax

Practice location:
  • Phone: 814-452-5100
  • Fax:
Mailing address:
  • Phone: 814-452-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: