Provider Demographics
NPI:1194563734
Name:GOOD, JACOB DALE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DALE
Last Name:GOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1118 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3909
Practice Address - Country:US
Practice Address - Phone:574-360-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program