Provider Demographics
NPI:1437121829
Name:JACOB, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
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 1:19460 CALADESI DR
Mailing Address - Street 2:APT/SUITE
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5572
Mailing Address - Country:US
Mailing Address - Phone:913-707-0826
Mailing Address - Fax:417-772-7019
Practice Address - Street 1:19460 CALADESI DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-5572
Practice Address - Country:US
Practice Address - Phone:913-707-0826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3D702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100154570DMedicaid
12485021OtherBCBS
MO203728035Medicaid
12485021OtherBCBS
0000574AMedicare ID - Type Unspecified