Provider Demographics
NPI:1780113886
Name:THOMAS, JACOB WILLIAM (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOVER AIR FORCE BASE
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5003
Mailing Address - Country:US
Mailing Address - Phone:026-776-5273
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AIR FORCE BASE
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-677-6527
Practice Address - Fax:026-776-5273
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125071136390200000X
WI7286321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program