Basic Information
| Provider Information | |||||||||
| NPI: | 1972658771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 FALLS BLVD S | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723963501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702383261 | ||||||||
| FaxNumber: | 8702383115 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 FALLS BLVD S | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723963501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702383261 | ||||||||
| FaxNumber: | 8702383115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C4111 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102032001 | 05 | AR | MEDICAID |