Provider Demographics
NPI:1164653853
Name:JACOB, SAJISH EAPEN (MD)
Entity Type:Individual
Prefix:MR
First Name:SAJISH
Middle Name:EAPEN
Last Name:JACOB
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 1:811 W INTERSTATE 20 STE 224
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5873
Mailing Address - Country:US
Mailing Address - Phone:817-641-6000
Mailing Address - Fax:
Practice Address - Street 1:811 W INTERSTATE 20 STE 224
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5873
Practice Address - Country:US
Practice Address - Phone:817-641-6000
Practice Address - Fax:817-419-4501
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 515952084N0600X
TXR97822084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology