Provider Demographics
NPI:1497762694
Name:JACOBS, ROLAND W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:W
Last Name:JACOBS
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:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1770
Mailing Address - Country:US
Mailing Address - Phone:575-770-7892
Mailing Address - Fax:
Practice Address - Street 1:150 CERRITO-COLORADO RD.
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:NM
Practice Address - Zip Code:87580
Practice Address - Country:US
Practice Address - Phone:575-770-7892
Practice Address - Fax:575-776-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG434602084P0800X
NM91-2252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8129228Medicaid
CA900521077OtherPROVIDER #
CAWG43460BOtherINDIVIDUAL PTAN
NM80077226Medicaid
CAWG43460BOtherMEDICARE PTAN
CA8129228Medicaid