Provider Demographics
NPI:1821210212
Name:LISTON, JACOB CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CHARLES
Last Name:LISTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:CHARLES
Other - Last Name:LISTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6545 FRANCE AVENUE SOUTH
Mailing Address - Street 2:SUITE 510
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-927-7079
Mailing Address - Fax:952-920-9758
Practice Address - Street 1:6545 FRANCE AVENUE SOUTH
Practice Address - Street 2:SUITE 510
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-927-7079
Practice Address - Fax:952-920-9758
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine