Provider Demographics
NPI:1992274179
Name:JACOB, SHRUTHY
Entity type:Individual
Prefix:
First Name:SHRUTHY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 BENWICK WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5596
Mailing Address - Country:US
Mailing Address - Phone:972-410-0021
Mailing Address - Fax:
Practice Address - Street 1:1300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-2037
Practice Address - Country:US
Practice Address - Phone:903-465-7442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist