Provider Demographics
NPI:1790163962
Name:JACOB, CHRIS (DO)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX MED
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-4912
Mailing Address - Fax:585-276-2144
Practice Address - Street 1:24211 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1151
Practice Address - Country:US
Practice Address - Phone:586-498-0440
Practice Address - Fax:586-498-0401
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY293779208M00000X
MI5101021621390200000X, 207R00000X
MI5151009894390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine