Provider Demographics
NPI:1265411979
Name:STEPHENSON, JACOB T (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:T
Last Name:STEPHENSON
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 1:1102 BATES AVE # FC1440
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2698
Mailing Address - Country:US
Mailing Address - Phone:832-828-3660
Mailing Address - Fax:
Practice Address - Street 1:1102 BATES AVE # FC1440
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2698
Practice Address - Country:US
Practice Address - Phone:832-828-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU5819208600000X, 2086S0120X
CA922642086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN