Provider Demographics
NPI:1619262227
Name:JAKOB, KYLE AUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:AUSTIN
Last Name:JAKOB
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:BH 634
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:16777 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3254
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-754-3265
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.206091208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2148427Medicaid
LAINTERNMedicaid
MS01954729Medicaid
MS01954729Medicaid