Provider Demographics
NPI:1891018339
Name:CHENNAT, JACOB BONAVENTURE (RPH)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:BONAVENTURE
Last Name:CHENNAT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 RAVEN CT
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8692
Mailing Address - Country:US
Mailing Address - Phone:817-656-0191
Mailing Address - Fax:817-656-0158
Practice Address - Street 1:1050 W SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060
Practice Address - Country:US
Practice Address - Phone:972-254-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist