Healthcare Provider Details

I. General information

NPI: 1851900047
Provider Name (Legal Business Name): MR. JACOB LOUIS SLANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 COLLEGE AVE
CLEMSON SC
29631-1441
US

IV. Provider business mailing address

408 COLLEGE AVE
CLEMSON SC
29631-1441
US

V. Phone/Fax

Practice location:
  • Phone: 864-650-0804
  • Fax:
Mailing address:
  • Phone: 864-650-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number303469
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: