Basic Information
| Provider Information | |||||||||
| NPI: | 1508530874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUTH | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4145 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197213999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4145 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178897500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2021029342 | MO | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.