Provider Demographics
NPI:1235499419
Name:JACOB, JASMINE ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:JASMINE
Middle Name:ROSE
Last Name:JACOB
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 1:620 10TH ST N STE 2A
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1407
Mailing Address - Country:US
Mailing Address - Phone:727-824-8243
Mailing Address - Fax:727-824-8233
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-8243
Practice Address - Fax:727-824-8233
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME126616207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018755400Medicaid
FL018755400Medicaid
FLIR714ZMedicare PIN