Provider Demographics
NPI:1578267985
Name:SU, JACOB CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:SU
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 1:3406 LA BRANCH ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-3845
Mailing Address - Country:US
Mailing Address - Phone:817-875-6517
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN ST STE 1700
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1526
Practice Address - Country:US
Practice Address - Phone:713-486-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program