Provider Demographics
NPI:1720367055
Name:TAYLOR, JACOB MARSHALL (DO, MPH)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARSHALL
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO, MPH
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 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-728-1663
Mailing Address - Fax:
Practice Address - Street 1:905 E COLBY ST STE 100
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461
Practice Address - Country:US
Practice Address - Phone:231-728-5910
Practice Address - Fax:231-728-5918
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022331171000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720367055Medicaid