Provider Demographics
NPI:1043067770
Name:PREMO, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PREMO
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:PO BOX 738
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-0738
Mailing Address - Country:US
Mailing Address - Phone:419-352-7588
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 738
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-0738
Practice Address - Country:US
Practice Address - Phone:419-352-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator