Provider Demographics
NPI:1770584112
Name:JACOB, GEORGE I (DC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:I
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:PO BOX 578700
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8700
Mailing Address - Country:US
Mailing Address - Phone:209-551-7246
Mailing Address - Fax:
Practice Address - Street 1:1908 COFFEE RD STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2719
Practice Address - Country:US
Practice Address - Phone:209-985-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4532436Medicaid
CA4532436Medicaid