Basic Information
| Provider Information | |||||||||
| NPI: | 1619262227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAKOB | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | AUSTIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HWY | ||||||||
| Address2: | BH 634 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701212429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16777 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257615200 | ||||||||
| FaxNumber: | 2257543265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | MD.206091 | LA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2148427 | 05 | LA | MEDICAID | INTERN | 05 | LA | MEDICAID | 01954729 | 05 | MS | MEDICAID |