Healthcare Provider Details

I. General information

NPI: 1780983312
Provider Name (Legal Business Name): JACOB D. SHANK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4808 N 24TH ST STE 125
PHOENIX AZ
85016-9120
US

IV. Provider business mailing address

4808 N 24TH ST STE 125
PHOENIX AZ
85016-9120
US

V. Phone/Fax

Practice location:
  • Phone: 602-551-6271
  • Fax:
Mailing address:
  • Phone: 602-551-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number49186
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number49186
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: