Provider Demographics
NPI:1497780571
Name:JACOB, KATHERINE NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICHOLAS
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 1:1105 CENTRAL EXPY N STE 2360
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6116
Mailing Address - Country:US
Mailing Address - Phone:214-547-7557
Mailing Address - Fax:214-547-7560
Practice Address - Street 1:1105 CENTRAL EXPY N STE 2360
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6116
Practice Address - Country:US
Practice Address - Phone:214-547-7557
Practice Address - Fax:214-547-7560
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2344207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0031MYOtherBLUE CROSS/BLUE SHIELD TX
TX176680001Medicaid
TX8F1335Medicare ID - Type Unspecified
TX0031MYOtherBLUE CROSS/BLUE SHIELD TX