Provider Demographics
NPI:1447739701
Name:JEZAK, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JEZAK
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 1:3605 LE MANS CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-2937
Mailing Address - Country:US
Mailing Address - Phone:817-253-5370
Mailing Address - Fax:
Practice Address - Street 1:230 S CLARK RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2750
Practice Address - Country:US
Practice Address - Phone:972-291-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2139333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant