Basic Information
| Provider Information | |||||||||
| NPI: | 1003895962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12368 STRATFORD DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152269810 | ||||||||
| FaxNumber: | 5159612714 | ||||||||
| Practice Location | |||||||||
| Address1: | 12368 STRATFORD DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152269810 | ||||||||
| FaxNumber: | 5159612714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 33546 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 668214600 | 05 | MN | MEDICAID |