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General NPI Number Information
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NPI Number | 1679109482
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Entity Type | Individual
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Provider Name | ADDISON F JACOBS MD
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Gender | Male
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Dates
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Enumeration Date | 03/13/2020
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 310 W LOSEY ST
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City | SCOTT AIR FORCE BASE
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State | IL
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Zip | 62225-5250
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Country | US
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Telephone | 618-256-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 310 W LOSEY ST
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City | SCOTT AIR FORCE BASE
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State | IL
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Zip | 62225-5250
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Country | US
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Telephone | 618-256-9355
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 33917
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 33917
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License Number State | NE
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