Basic Information
| Provider Information | |||||||||
| NPI: | 1790163962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | CHRIS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX MED | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852754912 | ||||||||
| FaxNumber: | 5852762144 | ||||||||
| Practice Location | |||||||||
| Address1: | 24211 LITTLE MACK AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480801151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864980440 | ||||||||
| FaxNumber: | 5864980401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 293779 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | 5101021621 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 5101021621 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 5151009894 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.