Provider Demographics
NPI:1124788450
Name:DEVRIES, JACOB MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MICHAEL
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 S WATSON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-3435
Mailing Address - Country:US
Mailing Address - Phone:602-598-5077
Mailing Address - Fax:
Practice Address - Street 1:825 S WATSON RD STE 105
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-3435
Practice Address - Country:US
Practice Address - Phone:602-598-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8975111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor