MEDICARE: KRISTEN JACOBS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	4301055183	MI
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	01037063	IN

General Provider Information

NPI Number	:	1962594929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN JACOBS M.D.

Provider Business Mailing Address
First Line	:	3355 DOUGLAS RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1779
Country	:	US
Telephone Number	:	574-234-4176
Fax Number	:	574-234-1561

Provider Business Practice Location Address
First Line	:	3355 DOUGLAS RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1779
Country	:	US
Telephone Number	:	574-234-4176
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	01/05/2024

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