Provider Demographics
NPI:1558867127
Name:MACE, JACOB DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:MACE
Suffix:
Gender:M
Credentials:DO
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-2332
Practice Address - Country:US
Practice Address - Phone:434-924-2231
Practice Address - Fax:434-924-9295
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206549207P00000X, 207PT0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program