1972563609 NPI number — DR. JONATHAN H JACOBS D.D.S.

Table of content: DR. JONATHAN H JACOBS D.D.S. (NPI 1972563609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972563609 NPI number — DR. JONATHAN H JACOBS D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
JONATHAN
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972563609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22811 GREATER MACK AVE
Provider Second Line Business Mailing Address:
STE. L-10
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080-2021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-774-2400
Provider Business Mailing Address Fax Number:
586-774-2461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22811 GREATER MACK AVE
Provider Second Line Business Practice Location Address:
STE. L-10
Provider Business Practice Location Address City Name:
ST CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-774-2400
Provider Business Practice Location Address Fax Number:
586-774-2461
Provider Enumeration Date:
03/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901012905 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 689419 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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