Healthcare Provider Details

I. General information

NPI: 1316972169
Provider Name (Legal Business Name): CHRISTINE K JACOBS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 05/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008008951
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: