Provider Demographics
NPI:1134141369
Name:JACOB, MOSES (DC)
Entity type:Individual
Prefix:DR
First Name:MOSES
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GRANT AVE
Mailing Address - Street 2:SUITE 100-B
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3150
Mailing Address - Country:US
Mailing Address - Phone:415-892-0974
Mailing Address - Fax:415-892-6284
Practice Address - Street 1:1500 GRANT AVE
Practice Address - Street 2:SUITE 100-B
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3150
Practice Address - Country:US
Practice Address - Phone:415-892-0974
Practice Address - Fax:415-892-6284
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0117470Medicare ID - Type UnspecifiedPROVIDER NUMBER