Provider Demographics
NPI:1568474195
Name:JACOBS, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 504
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-662-4333
Mailing Address - Fax:248-662-3022
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 504
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-662-4333
Practice Address - Fax:248-662-3022
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMJ068638208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4569968Medicaid
MION78940Medicare ID - Type Unspecified
H63445Medicare UPIN