Provider Demographics
NPI:1003275264
Name:MOULDS, JACOB (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MOULDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-4009
Mailing Address - Country:US
Mailing Address - Phone:415-292-3440
Mailing Address - Fax:
Practice Address - Street 1:3061 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4009
Practice Address - Country:US
Practice Address - Phone:415-292-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS163072084P0800X
390200000X
CA20A182772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program