Provider Demographics
NPI:1831787431
Name:SMITH, JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SMITH
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:NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:541-990-2091
Mailing Address - Fax:
Practice Address - Street 1:1300 HELICOPTER RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8913
Practice Address - Country:US
Practice Address - Phone:757-763-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
VA0102208723171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program