Healthcare Provider Details

I. General information

NPI: 1104271956
Provider Name (Legal Business Name): JACOB HAYES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 22ND ST
LUBBOCK TX
79410-1115
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-0030
  • Fax: 806-725-0015
Mailing address:
  • Phone: 314-577-5634
  • Fax: 314-577-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2019010646
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberT5123
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: