Provider Demographics
NPI:1346359866
Name:JACOBS, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:1541 FLORIDA AVE STE 305
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4439
Practice Address - Country:US
Practice Address - Phone:209-575-5833
Practice Address - Fax:209-575-5836
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01583363A00000X
ALPA.1502363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1017889OtherNCCPA
CAPA12419OtherSTATE PA LICENSE
KY9500618500Medicaid
1017889OtherNCCPA
KYR40749Medicare UPIN