Provider Demographics
NPI:1750878823
Name:JACOB, CHRISTOPHER THOMAS
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLAWNOX
Mailing Address - State:PA
Mailing Address - Zip Code:15238-3362
Mailing Address - Country:US
Mailing Address - Phone:469-688-1993
Mailing Address - Fax:
Practice Address - Street 1:4401 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1334
Practice Address - Country:US
Practice Address - Phone:412-692-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-15
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67028411A183700000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183700000XPharmacy Service ProvidersPharmacy Technician