Healthcare Provider Details

I. General information

NPI: 1245686518
Provider Name (Legal Business Name): JAKOB A DEVORE LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAKE A DEVORE LSA

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5309 CORN FIELD DR
FORT WORTH TX
76179-8163
US

IV. Provider business mailing address

5309 CORN FIELD DR
FORT WORTH TX
76179-8163
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number142172
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00729
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: