Healthcare Provider Details

I. General information

NPI: 1780113886
Provider Name (Legal Business Name): JACOB WILLIAM THOMAS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 01/10/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD
DOVER AIR FORCE BASE DE
19902-5003
US

IV. Provider business mailing address

300 TUSKEGEE BLVD
DOVER AIR FORCE BASE DE
19902-5003
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-6527
  • Fax: 26-776-5273
Mailing address:
  • Phone: 26-776-5273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125071136
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7286321
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: