Healthcare Provider Details

I. General information

NPI: 1063477545
Provider Name (Legal Business Name): JEFFRY ALAN JACOBS MEDICAL DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 FARAON ST
SAINT JOSEPH MO
64506-3044
US

IV. Provider business mailing address

12932 ORCHARD CROSSING LN
KNOXVILLE TN
37934-1222
US

V. Phone/Fax

Practice location:
  • Phone: 816-232-4417
  • Fax:
Mailing address:
  • Phone: 865-202-2209
  • Fax: 865-321-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35908KY
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD60579729
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD38701
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2022007260
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: