Provider Demographics
NPI:1881924819
Name:JACOB, ALEXIS DANIELLE (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:DANIELLE
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-2961
Practice Address - Street 1:700 S PARK ST STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-2961
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10023656208600000X
TXN68912086S0129X
WI77962-202086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881924819Medicaid