Basic Information
| Provider Information | |||||||||
| NPI: | 1255411617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 E HIGHWAY 290 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787231142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124839596 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 6835 AUSTIN CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787313166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123466611 | ||||||||
| FaxNumber: | 5122315203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M9924 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2005-01503 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 205067601 | 05 | TX | MEDICAID | 205067602 | 05 | TX | MEDICAID | 205067603 | 05 | TX | MEDICAID | 50902903 | 05 | NC | MEDICAID |