Provider Demographics
NPI:1033107636
Name:JACOB, ANNE USHA (MBBS)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:USHA
Last Name:JACOB
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 PAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3807
Mailing Address - Country:US
Mailing Address - Phone:314-288-0071
Mailing Address - Fax:314-758-5210
Practice Address - Street 1:3649 PAGE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3807
Practice Address - Country:US
Practice Address - Phone:314-288-0071
Practice Address - Fax:314-758-5210
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42911207Q00000X
MO2015008169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350431000Medicaid
MN350431000Medicaid