MEDICARE: JACOB IAN PRIESTER

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

General Provider Information

NPI Number	:	1306498209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB IAN PRIESTER

Provider Business Mailing Address
First Line	:	2625 53RD ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-1629
Country	:	US
Telephone Number	:	209-620-1416
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 53RD ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-1629
Country	:	US
Telephone Number	:	209-620-1416
Fax Number	:

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

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/10/2019

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Directions to “ JACOB IAN PRIESTER ” Practice Location

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