Healthcare Provider Details

I. General information

NPI: 1962594929
Provider Name (Legal Business Name): KRISTEN JACOBS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

IV. Provider business mailing address

3355 DOUGLAS RD
SOUTH BEND IN
46635-1779
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-4176
  • Fax:
Mailing address:
  • Phone: 574-234-4176
  • Fax: 574-234-1561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301055183
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01037063
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: