Healthcare Provider Details

I. General information

NPI: 1629430269
Provider Name (Legal Business Name): GREGORY JACOB JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 W 11TH AVE
COVINGTON LA
70433-2318
US

IV. Provider business mailing address

PO BOX 669379
DALLAS TX
75266-9379
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-3766
  • Fax:
Mailing address:
  • Phone: 985-892-3766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number307297
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: