Provider Demographics
NPI:1063686152
Name:SKINNER, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SKINNER
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 1:1528 W WARM SPRINGS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-4332
Mailing Address - Country:US
Mailing Address - Phone:702-737-1880
Mailing Address - Fax:702-650-0763
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7826
Practice Address - Country:US
Practice Address - Phone:702-737-1880
Practice Address - Fax:702-650-0763
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81015207V00000X
NV13197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1063686152Medicaid
AZ81015OtherTRAINING PERMIT
NVP01375794OtherRAILROAD MEDICARE
NVP01375794OtherRAILROAD MEDICARE