Provider Demographics
NPI:1255482063
Name:JACOB, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
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 1:3600 PRYTANIA ST
Mailing Address - Street 2:SUITE 35
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3628
Mailing Address - Country:US
Mailing Address - Phone:504-897-7197
Mailing Address - Fax:
Practice Address - Street 1:3525 PRYTANIA STREET
Practice Address - Street 2:SUITE 206
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115
Practice Address - Country:US
Practice Address - Phone:504-897-8281
Practice Address - Fax:504-897-5604
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011071207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1943479Medicaid
LA1133191Medicaid
LA110115653Medicare PIN
B63844Medicare UPIN
LA1943479Medicaid