Provider Demographics
NPI:1568416493
Name:JACOB, JOSEPH P (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:JACOB
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 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-495-8490
Mailing Address - Fax:970-484-5682
Practice Address - Street 1:2695 ROCKY MOUNTAIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8702
Practice Address - Country:US
Practice Address - Phone:970-495-8490
Practice Address - Fax:970-484-5682
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43793208100000X
CODR.0043793204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123553200Medicaid
CO19835027Medicaid
P00311590OtherRAILROAD MEDICARE
P00311590OtherRAILROAD MEDICARE
WY123553200Medicaid
COCOA107073Medicare PIN
COC53781Medicare UPIN