Basic Information
| Provider Information | |||||||||
| NPI: | 1245686518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVORE | ||||||||
| FirstName: | JAKOB | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEVORE | ||||||||
| OtherFirstName: | JAKE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5309 CORN FIELD DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761798163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Practice Location | |||||||||
| Address1: | 5309 CORN FIELD DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761798163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2016 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 142172 | KS | N | 246ZC0007X | SA00729 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.