Healthcare Provider Details

I. General information

NPI: 1053466763
Provider Name (Legal Business Name): MACARA K JACOBS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR STE 350
SAINT LOUIS MO
63141-8669
US

IV. Provider business mailing address

PO BOX 14369
SAINT LOUIS MO
63178-4369
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-6071
  • Fax: 314-453-9965
Mailing address:
  • Phone: 314-567-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2024022107
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.010556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: