Provider Demographics
NPI:1508453473
Name:JACOB, JUSTIN JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JOSEPH
Last Name:JACOB
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 BERKLEY PKWY APT 253
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64120-1475
Mailing Address - Country:US
Mailing Address - Phone:636-699-3529
Mailing Address - Fax:
Practice Address - Street 1:7003 E BANNISTER RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-1672
Practice Address - Country:US
Practice Address - Phone:816-761-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018041600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist