Healthcare Provider Details

I. General information

NPI: 1134157597
Provider Name (Legal Business Name): MICHAEL KEITH JACOBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 MONTCLAIR RD SUITE 105
MOUNTAIN BRK AL
35213-2425
US

IV. Provider business mailing address

1010 AIRPARK CENTER DR
NASHVILLE TN
37217-5200
US

V. Phone/Fax

Practice location:
  • Phone: 205-705-3550
  • Fax: 205-705-3554
Mailing address:
  • Phone: 615-221-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME100342
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD.201843
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2008-00217
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number0101245015
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number25031
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberDR0050087
License Number StateCO
# 7
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number21330
License Number StateMS
# 8
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number25MA08863300
License Number StateNJ
# 9
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberN2577
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberE6005
License Number StateAR
# 11
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD31313
License Number StateSC
# 12
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA110841
License Number StateCA
# 13
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number42796
License Number StateTN
# 14
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number060107
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: