Healthcare Provider Details

I. General information

NPI: 1437311081
Provider Name (Legal Business Name): JACOB MAYBERRY AS-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BLUE WATER DR
BRIDGEPORT TX
76426-4336
US

IV. Provider business mailing address

104 BLUE WATER DR
BRIDGEPORT TX
76426-4336
US

V. Phone/Fax

Practice location:
  • Phone: 940-683-8078
  • Fax: 940-683-8078
Mailing address:
  • Phone: 940-683-8078
  • Fax: 940-683-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberTC08-0326A
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: