Healthcare Provider Details

I. General information

NPI: 1346332939
Provider Name (Legal Business Name): JACOB T JOSEPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10721 MAIN ST SUITE 1100
FAIRFAX VA
22030-6914
US

IV. Provider business mailing address

10721 MAIN ST SUITE 1100
FAIRFAX VA
22030-6914
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-4762
  • Fax: 703-591-7719
Mailing address:
  • Phone: 703-273-4762
  • Fax: 703-591-7719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101034461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: