Individual
JACOB SHANE TEBBS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
6051 N EAGLE RD, BOISE, ID 83713-0997
(208) 519-4333
(208) 205-9134
Mailing address
1900 N STATE ST, PROVO, UT 84604-1305
(801) 373-2001
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
10103875-1206
UT
Other
Enumeration date
09/29/2016
Last updated
08/07/2020
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