Provider Demographics
NPI:1689172306
Name:NEWSOME, JACOB DANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DANIEL
Last Name:NEWSOME
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 AVENIDA FRONTERA
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-7732
Mailing Address - Country:US
Mailing Address - Phone:609-231-8485
Mailing Address - Fax:
Practice Address - Street 1:1131 AVENIDA FRONTERA
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-7732
Practice Address - Country:US
Practice Address - Phone:609-231-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255A2300X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer