Basic Information
| Provider Information | |||||||||
| NPI: | 1962587287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8405 E. BASELINE RD. | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806152010 | ||||||||
| FaxNumber: | 4802186053 | ||||||||
| Practice Location | |||||||||
| Address1: | 8405 E. BASELINE RD. | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806152010 | ||||||||
| FaxNumber: | 4802186053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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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 | 208000000X | 0101030878 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 38147 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6737846 | 05 | VA | MEDICAID | 102616 | 05 | AZ | MEDICAID |