MEDICARE: JACOB T STEPHENSON MD

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	208600000X	Surgery Physician	U5819	TX
2	2086S0120X	Pediatric Surgery Physician	92264	CA
3	2086S0120X	Pediatric Surgery Physician	U5819	TX

General Provider Information

NPI Number	:	1265411979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB T STEPHENSON MD

Provider Business Mailing Address
First Line	:	1102 BATES AVE # FC1440
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2698
Country	:	US
Telephone Number	:	832-828-3660
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 BATES AVE # FC1440
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2698
Country	:	US
Telephone Number	:	832-828-3660
Fax Number	:

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	01/07/2024

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