Provider Demographics
NPI:1023507035
Name:ANDERSON, JACOB (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ANDERSON
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 1:260895 COUNTY RD E # 1
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-6907
Mailing Address - Country:US
Mailing Address - Phone:435-754-8044
Mailing Address - Fax:
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-630-2100
Practice Address - Fax:308-630-1349
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063543207Q00000X
NE3013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty