Provider Demographics
NPI:1750303160
Name:LOCKE, JACOB EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:LOCKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACOB
Other - Middle Name:EDWARD
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3139 W HOLCOMBE BLVD # 550
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1533
Mailing Address - Country:US
Mailing Address - Phone:937-689-5169
Mailing Address - Fax:
Practice Address - Street 1:3139 W HOLCOMBE BLVD # 550
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1533
Practice Address - Country:US
Practice Address - Phone:937-689-5169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN38432085R0001X
OH350852072085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
201572741OtherTRICARE
P00201720OtherRR MEDICARE
201572741OtherMEDICAL MUTUAL
OH2250942Medicaid
201572741027OtherCARESOURCE
000000353030OtherANTHEM
201572741027OtherCARESOURCE
000000353030OtherANTHEM
OHL04149031Medicare PIN