Provider Demographics
NPI:1174191746
Name:GLEASON, JACOB LATHARY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LATHARY
Last Name:GLEASON
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 1:2226 GREGG RD APT 6
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-7714
Mailing Address - Country:US
Mailing Address - Phone:402-672-7566
Mailing Address - Fax:
Practice Address - Street 1:819 TARA PLZ
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-2043
Practice Address - Country:US
Practice Address - Phone:402-512-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician