Healthcare Provider Details

I. General information

NPI: 1689137788
Provider Name (Legal Business Name): BENJAMIN JOHNSON JACOBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 COVE RD
VIRGINIA BEACH VA
23459-8911
US

IV. Provider business mailing address

2000 TRIDENT WAY
SAN DIEGO CA
92155-5599
US

V. Phone/Fax

Practice location:
  • Phone: 757-763-2060
  • Fax:
Mailing address:
  • Phone: 619-407-0214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101270564
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: