Provider Demographics
NPI:1063282440
Name:WINCHESTER, JACOB RAY (PA STUDENT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RAY
Last Name:WINCHESTER
Suffix:
Gender:
Credentials:PA STUDENT
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:713 ASH ST
Mailing Address - Street 2:
Mailing Address - City:VANDENBERG AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93437-1357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-605-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant