Provider Demographics
NPI:1225097538
Name:JACOBE, HEIDI (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:JACOBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9069
Mailing Address - Country:US
Mailing Address - Phone:214-648-2985
Mailing Address - Fax:214-648-9292
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9069
Practice Address - Country:US
Practice Address - Phone:214-648-2985
Practice Address - Fax:214-648-9292
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5314207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153700301Medicaid
TX153700301Medicaid
TXJA08687B7Medicare ID - Type Unspecified