Provider Demographics
NPI:1043825698
Name:SMITH, JACOB
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 W SOUTHERN AVE APT 2006
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4968
Mailing Address - Country:US
Mailing Address - Phone:602-488-6496
Mailing Address - Fax:
Practice Address - Street 1:960 W SOUTHERN AVE APT 2006
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4968
Practice Address - Country:US
Practice Address - Phone:602-488-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor