Basic Information
| Provider Information | |||||||||
| NPI: | 1376025742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANOW | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4611 SW 48TH WAY APT. 107 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526340767 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 NW 43RD ST UNIT 401 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523760585 | ||||||||
| FaxNumber: | 3523751290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2018 | ||||||||
| LastUpdateDate: | 09/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PSI33756 | FL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.