Provider Demographics
NPI:1063492486
Name:JACOB, KEVIN CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:JACOB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-8751
Mailing Address - Country:US
Mailing Address - Phone:910-678-2414
Mailing Address - Fax:810-678-3936
Practice Address - Street 1:3820 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-8751
Practice Address - Country:US
Practice Address - Phone:910-678-2414
Practice Address - Fax:810-678-3936
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008846111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV03182Medicare UPIN