Provider Demographics
NPI:1780440792
Name:BEVELL, JACOB ROLAND (DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROLAND
Last Name:BEVELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 TIERRA BUENA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-4944
Mailing Address - Country:US
Mailing Address - Phone:702-863-9499
Mailing Address - Fax:
Practice Address - Street 1:2550 NATURE PARK DR STE 250
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-3206
Practice Address - Country:US
Practice Address - Phone:702-863-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist