Provider Demographics
NPI:1447943428
Name:MATHY, JACOB CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:MATHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 W EQUESTRIAN PL APT 1317
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-6814
Mailing Address - Country:US
Mailing Address - Phone:608-790-0719
Mailing Address - Fax:
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8170
Practice Address - Country:US
Practice Address - Phone:605-322-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD318222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry