Basic Information
| Provider Information | |||||||||
| NPI: | 1003225855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | GALLO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343750 | ||||||||
| FaxNumber: | 2109220162 | ||||||||
| Practice Location | |||||||||
| Address1: | 6315 S ZARZAMORA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782113218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109771900 | ||||||||
| FaxNumber: | 2109779326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09391 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 340243001 | 05 | TX | MEDICAID |