Provider Demographics
NPI:1174148936
Name:OLIVER, JACOB LEE (SLP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
Last Name:OLIVER
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0639
Mailing Address - Country:US
Mailing Address - Phone:479-495-6252
Mailing Address - Fax:
Practice Address - Street 1:719 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-9607
Practice Address - Country:US
Practice Address - Phone:479-495-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200110235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist