Provider Demographics
NPI:1033548045
Name:JACOB, MICHELLE VERONICA (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:VERONICA
Last Name:JACOB
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Gender:F
Credentials:NP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-7785
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2021-11-15
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Provider Licenses
StateLicense IDTaxonomies
IL209011680363LA2200X
MO2013044500363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420022730Medicaid