Provider Demographics
NPI:1942794458
Name:COMPTON, JACOB RYAN (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:COMPTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22101 MOROSS RD STE 50
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2172
Mailing Address - Country:US
Mailing Address - Phone:313-343-7774
Mailing Address - Fax:
Practice Address - Street 1:19251 MACK AVE STE 333
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2898
Practice Address - Country:US
Practice Address - Phone:313-343-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026132207R00000X
MI5101024103207R00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program