Basic Information
| Provider Information | |||||||||
| NPI: | 1740290964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKIWSKI | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 N LEHMBERG RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397025554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623292955 | ||||||||
| FaxNumber: | 6623286007 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N LEHMBERG RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397025554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623292955 | ||||||||
| FaxNumber: | 6623286007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 08454 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 009924150 | 05 | AL | MEDICAID | 00016905 | 05 | MS | MEDICAID |