Healthcare Provider Details

I. General information

NPI: 1780003442
Provider Name (Legal Business Name): JACOB ALEXANDER DO, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N. MUNDO
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 187
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax: 575-759-7294
Mailing address:
  • Phone: 575-759-3291
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberDR.0057889
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberDO2025-0114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: