Provider Demographics
NPI:1700621497
Name:BALL, JACOB PATRICK
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PATRICK
Last Name:BALL
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 1:2939 RUGGLES DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-1948
Mailing Address - Country:US
Mailing Address - Phone:407-415-6055
Mailing Address - Fax:
Practice Address - Street 1:1775 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5067
Practice Address - Country:US
Practice Address - Phone:407-606-7858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician