MEDICARE: DR. KENNETH MICHAEL JACOB 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	2085R0202X	Diagnostic Radiology Physician	R3D70	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	12485021	OTHER	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437121829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH MICHAEL JACOB MD

Provider Business Mailing Address
First Line	:	19460 CALADESI DR
Second Line	:	APT/SUITE
City	:	FORT MYERS
State	:	FL
Zip	:	33967-5572
Country	:	US
Telephone Number	:	913-707-0826
Fax Number	:	417-772-7019

Provider Business Practice Location Address
First Line	:	19460 CALADESI DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-5572
Country	:	US
Telephone Number	:	913-707-0826
Fax Number	:

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	11/13/2013

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