Provider Demographics
NPI:1891465159
Name:JACOBS, JUSTIN S JR
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:JACOBS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HOLLAND AVE APT 130
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2427
Mailing Address - Country:US
Mailing Address - Phone:530-908-5347
Mailing Address - Fax:
Practice Address - Street 1:6580 FM 78
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1300
Practice Address - Country:US
Practice Address - Phone:210-666-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310877183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician