Basic Information
| Provider Information | |||||||||
| NPI: | 1063686152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKINNER | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1528 W WARM SPRINGS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890144332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027371880 | ||||||||
| FaxNumber: | 7026500763 | ||||||||
| Practice Location | |||||||||
| Address1: | 4475 S EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891197826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027371880 | ||||||||
| FaxNumber: | 7026500763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 81015 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 13197 | NV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1063686152 | 05 | NV | MEDICAID |