Provider Demographics
NPI:1023123668
Name:JACOBS, JONATHAN S (DMD,MD,FACS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DMD,MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 FIRST COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3037
Mailing Address - Country:US
Mailing Address - Phone:757-491-3535
Mailing Address - Fax:757-422-4750
Practice Address - Street 1:1037 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3037
Practice Address - Country:US
Practice Address - Phone:757-491-3535
Practice Address - Fax:757-422-4750
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030062208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101030062OtherMEDICAL LICENSE
VA7601972Medicaid
VAC06224OtherMEDICARE GROU
VA240000242Medicare PIN
VAB10154Medicare UPIN