Healthcare Provider Details

I. General information

NPI: 1659369031
Provider Name (Legal Business Name): THOMAS E. JACOB, D.P.M., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23700 GRATIOT AVE
EASTPOINTE MI
48021-1647
US

IV. Provider business mailing address

23700 GRATIOT AVE
EASTPOINTE MI
48021-1647
US

V. Phone/Fax

Practice location:
  • Phone: 586-779-1160
  • Fax: 586-779-1163
Mailing address:
  • Phone: 586-779-1160
  • Fax: 586-779-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number59010000499
License Number StateMI

VIII. Authorized Official

Name: MRS. NANNETTE M. LINGEMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-779-1160