Provider Demographics
NPI:1801336524
Name:JACOB, DIANA MARY (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARY
Last Name:JACOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4416
Mailing Address - Country:US
Mailing Address - Phone:214-941-0032
Mailing Address - Fax:214-580-3514
Practice Address - Street 1:129 W 9TH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4416
Practice Address - Country:US
Practice Address - Phone:214-941-0032
Practice Address - Fax:214-580-3514
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX567258YNGSMedicaid
TX567259YL7BMedicaid
TX567256YL7AMedicaid