Provider Demographics
NPI:1922081249
Name:MARSHALL, JACOB C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:C
Last Name:MARSHALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BOWLER RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-7012
Mailing Address - Country:US
Mailing Address - Phone:618-977-9607
Mailing Address - Fax:618-624-9302
Practice Address - Street 1:103 N OAK ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1165
Practice Address - Country:US
Practice Address - Phone:888-577-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102192207Q00000X
IL036-102192207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102192Medicaid
IL036102192 -8Medicaid
IL036102192-9Medicaid
MO1922081249Medicaid
IL08232204OtherBLUE CROSS BLUE SHIELD
IL036102192-9Medicaid
ILIL1682041Medicare PIN
MO1922081249Medicaid
ILK30034Medicare PIN
IL214881051Medicare PIN