Basic Information
| Provider Information | |||||||||
| NPI: | 1871173146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1845 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177207170 | ||||||||
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| Practice Location | |||||||||
| Address1: | 60TH MEDICAL GROUP, DAVID GRANT MEDICAL CENTER | ||||||||
| Address2: | 101 BODIN CIR, UNIT 777 | ||||||||
| City: | APO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2021 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.