Provider Demographics
NPI:1821502154
Name:JACOB, MICHAEL BLAKE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BLAKE
Last Name:JACOB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5600 CAMERATA WAY UNIT 221
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5285
Mailing Address - Country:US
Mailing Address - Phone:612-590-3809
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2649
Practice Address - Country:US
Practice Address - Phone:763-577-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12595207XX0005X
MN12593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine