Provider Demographics
NPI:1023571114
Name:KALLSEN, JACOB ARTHUR (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ARTHUR
Last Name:KALLSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E SAUNDERS ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5474
Mailing Address - Country:US
Mailing Address - Phone:956-796-5000
Mailing Address - Fax:
Practice Address - Street 1:1700 E SAUNDERS ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5474
Practice Address - Country:US
Practice Address - Phone:956-796-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT7963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine