Provider Demographics
NPI:1427539055
Name:MAHAN, JACOB
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:MAHAN
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 1:4006 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5848
Mailing Address - Country:US
Mailing Address - Phone:904-247-4327
Mailing Address - Fax:904-247-4328
Practice Address - Street 1:1871 WELLS RD STE 10
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2350
Practice Address - Country:US
Practice Address - Phone:904-579-4814
Practice Address - Fax:904-247-4328
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5362237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist