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General NPI Number Information
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NPI Number | 1003760547
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Entity Type | Individual
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Provider Name | JACOB ANTHONY HUDDLESTON
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Gender | Male
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Dates
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Enumeration Date | 02/23/2026
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Last Update Date | 02/23/2026
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Provider Practice Location Address
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Address Line | 4873 E 12TH ST
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City | TUCSON
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State | AZ
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Zip | 85711-3603
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Country | US
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Telephone | 310-259-1861
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Fax |
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Provider Business Mailing Address
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Address Line | 272 WHITE BARK LN
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City | SIMI VALLEY
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State | CA
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Zip | 93065-4989
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Country | US
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Telephone | 310-259-1861
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | AZ
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