Provider Demographics
NPI:1316714926
Name:SCIVALLY, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SCIVALLY
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 1:1400 ANDREWS PKWY APT 2124
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-2961
Mailing Address - Country:US
Mailing Address - Phone:469-268-0635
Mailing Address - Fax:469-800-8335
Practice Address - Street 1:301 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1754
Practice Address - Country:US
Practice Address - Phone:254-202-1272
Practice Address - Fax:469-800-8335
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200639183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician