Provider Demographics
NPI:1508250846
Name:WHITSITT, JACOB CLARK (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CLARK
Last Name:WHITSITT
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 1:13123 E 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-7106
Mailing Address - Country:US
Mailing Address - Phone:720-848-0597
Mailing Address - Fax:
Practice Address - Street 1:100 COOK STREET
Practice Address - Street 2:SUITE 306
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206
Practice Address - Country:US
Practice Address - Phone:720-516-6405
Practice Address - Fax:720-516-9433
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0063067207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program