Healthcare Provider Details

I. General information

NPI: 1912760885
Provider Name (Legal Business Name): CHRISTOPHER ALAN JACOB PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35000 GUADALCANAL ST
SAN DIEGO CA
92140-5599
US

IV. Provider business mailing address

35000 GUADALCANAL ST
SAN DIEGO CA
92140-5599
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-1385
  • Fax: 619-524-8072
Mailing address:
  • Phone: 619-524-1385
  • Fax: 619-524-8072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14217533-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number14217533-1206
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: