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General NPI Number Information
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NPI Number | 1245686518
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Entity Type | Individual
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Provider Name | JAKOB A DEVORE LSA
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Gender | Male
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Dates
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Enumeration Date | 05/05/2016
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 5309 CORN FIELD DR
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City | FORT WORTH
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State | TX
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Zip | 76179-8163
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Country | US
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Telephone | 214-227-2457
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Fax | 214-764-0880
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Provider Business Mailing Address
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Address Line | 5309 CORN FIELD DR
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City | FORT WORTH
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State | TX
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Zip | 76179-8163
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Country | US
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Telephone | 214-227-2457
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Fax | 214-764-0880
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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 | 246ZS0410X
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Taxonomy Name | Surgical Technologist
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License Number | 142172
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | SA00729
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License Number State | TX
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