Provider Demographics
NPI:1972558245
Name:JACOBY, GAIL A (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:A
Last Name:JACOBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:ANN
Other - Last Name:JACOBY-LOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:SUITE 396
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-6550
Practice Address - Fax:503-216-6575
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074880Medicaid
OR074880Medicaid
OR133776Medicare PIN