Provider Demographics
NPI:1154870251
Name:TEBBS, JACOB SHANE (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SHANE
Last Name:TEBBS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1305
Mailing Address - Country:US
Mailing Address - Phone:801-373-2001
Mailing Address - Fax:
Practice Address - Street 1:6051 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0997
Practice Address - Country:US
Practice Address - Phone:208-519-4333
Practice Address - Fax:208-205-9134
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10103875-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical