Provider Demographics
NPI:1720030349
Name:JACOB, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843225
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3225
Mailing Address - Country:US
Mailing Address - Phone:708-633-1234
Mailing Address - Fax:708-342-7100
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:STE 344
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4910
Practice Address - Country:US
Practice Address - Phone:573-331-5515
Practice Address - Fax:573-331-5516
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36615207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203568324Medicaid
AR160306001Medicaid
P00262024OtherRAILROAD MEDICARE
188833OtherHEALTHLINK
MO444830OtherANTHEM BCBS
P00262024OtherRAILROAD MEDICARE
MO945023247Medicare PIN