MEDICARE: JACOB ANTHONY HUDDLESTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		AZ
2	2255A2300X	Athletic Trainer		AZ

General Provider Information

NPI Number	:	1003760547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ANTHONY HUDDLESTON

Provider Business Mailing Address
First Line	:	272 WHITE BARK LN
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-4989
Country	:	US
Telephone Number	:	310-259-1861
Fax Number	:

Provider Business Practice Location Address
First Line	:	4873 E 12TH ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3603
Country	:	US
Telephone Number	:	310-259-1861
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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