Healthcare Provider Details

I. General information

NPI: 1831787431
Provider Name (Legal Business Name): JACOB SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 HELICOPTER RD
VIRGINIA BEACH VA
23459-8913
US

IV. Provider business mailing address

NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 757-763-2007
  • Fax:
Mailing address:
  • Phone: 541-990-2091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102208723
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: