Provider Demographics
NPI:1235102831
Name:JACOBS, JESSIE PRUETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:PRUETT
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JESSE
Other - Middle Name:PRUETT
Other - Last Name:JACOBS
Other - Suffix:III
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:10651 E ST
Mailing Address - Street 2:ATTN: MARIA A. VILLAGOMEZ
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78419-5130
Mailing Address - Country:US
Mailing Address - Phone:361-961-4311
Mailing Address - Fax:361-961-2529
Practice Address - Street 1:10651 E ST
Practice Address - Street 2:ATTN: MARIA A. VILLAGOMEZ
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78419-5130
Practice Address - Country:US
Practice Address - Phone:361-961-4311
Practice Address - Fax:361-961-2529
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist