Provider Demographics
NPI:1821811522
Name:EUBANKS, JACOB OLLIS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:OLLIS
Last Name:EUBANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:OLLIS
Other - Last Name:EUBANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MT
Mailing Address - Street 1:1722 S GLENSTONE AVE STE J
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1513
Mailing Address - Country:US
Mailing Address - Phone:417-229-2822
Mailing Address - Fax:
Practice Address - Street 1:1722 S GLENSTONE AVE STE J
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1513
Practice Address - Country:US
Practice Address - Phone:417-229-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002439225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist