MEDICARE: ALEXANDER STEPHAN JACOBS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1225804453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER STEPHAN JACOBS

Provider Business Mailing Address
First Line	:	6056 E ROCHELLE ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-4209
Country	:	US
Telephone Number	:	480-862-0788
Fax Number	:

Provider Business Practice Location Address
First Line	:	6056 E ROCHELLE ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-4209
Country	:	US
Telephone Number	:	480-862-0788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2023
Last Update Date	:	11/29/2023

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