Provider Demographics
NPI:1043229800
Name:ROLAND W. JACOBS, MD, PC
Entity Type:Organization
Organization Name:ROLAND W. JACOBS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-770-7892
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0459
Mailing Address - Country:US
Mailing Address - Phone:505-770-7892
Mailing Address - Fax:505-776-3827
Practice Address - Street 1:1127 ROSARIO DR
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-3631
Practice Address - Country:US
Practice Address - Phone:505-770-7892
Practice Address - Fax:505-776-3827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG434602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92414Medicare UPIN
CAG43460Medicare ID - Type Unspecified