Healthcare Provider Details

I. General information

NPI: 1235499419
Provider Name (Legal Business Name): JASMINE ROSE JACOB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 10TH ST N
ST PETERSBURG FL
33705-1407
US

IV. Provider business mailing address

620 10TH ST N STE 2A
ST PETERSBURG FL
33705-1407
US

V. Phone/Fax

Practice location:
  • Phone: 727-824-8243
  • Fax: 727-824-8233
Mailing address:
  • Phone: 727-824-8243
  • Fax: 727-824-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME126616
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: