Basic Information
| Provider Information | |||||||||
| NPI: | 1932269396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | SUMA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WASHINGTON AVE SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
| FaxNumber: | 6122738727 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | SUITE 2A WEST | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
| FaxNumber: | 6122738727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 12/16/2014 | ||||||||
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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 | 2084P0800X | 56068 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 260003800 | 01 | MN | MEDICARE PTAN | OTHER | 1932269396 | 05 | MN | MEDICAID |