Basic Information
| Provider Information | |||||||||
| NPI: | 1396388674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 HANDSOME CAB LN APT 104 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073757856 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522533333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2019 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN11006614 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.