Provider Demographics
NPI:1255411617
Name:CHILDERS, JACOB A (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3166
Practice Address - Country:US
Practice Address - Phone:512-346-6611
Practice Address - Fax:512-231-5203
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9924207Q00000X
NC2005-01503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205067601Medicaid
TX205067602Medicaid
TX205067603Medicaid
NC50902903Medicaid
NC2050575HMedicare ID - Type UnspecifiedCHUC BALLANTYNE
TX8L18894Medicare PIN
NC2050575KMedicare ID - Type UnspecifiedCHUC EASTLAND
TX205067602Medicaid
NC2050575DMedicare ID - Type UnspecifiedCHUC MONROE
NC2050575BMedicare ID - Type UnspecifiedCHUC NORTHCROSS
TX8L18839Medicare PIN
NC2050575MMedicare ID - Type UnspecifiedCHUC COX RD
NC2050575AMedicare ID - Type UnspecifiedCHUC ARBORETUM
NC50902903Medicaid
TX205067601Medicaid
TXP00809963Medicare PIN