Basic Information
| Provider Information | |||||||||
| NPI: | 1497197016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAL | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | 3016682202 | ||||||||
| Practice Location | |||||||||
| Address1: | 626 TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | 3016682202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2013 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202006812 | VA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP-1452 | WV | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 07324 | MD | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 07324 | 01 | MD | STATE OF MARYLAND | OTHER | SLP-1452 | 01 | WV | WEST VIRGINIA BOARDNOF EXAMINERS | OTHER | 2202006812 | 01 | VA | COMMONWEALTH OF VIRGINIA | OTHER |