Provider Demographics
NPI:1063723781
Name:WARDWELL, JACOB O (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:O
Last Name:WARDWELL
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:450 SUTTER ST RM 1341
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4007
Mailing Address - Country:US
Mailing Address - Phone:415-606-0309
Mailing Address - Fax:415-862-0626
Practice Address - Street 1:450 SUTTER ST RM 1341
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4007
Practice Address - Country:US
Practice Address - Phone:415-606-0309
Practice Address - Fax:415-862-0626
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2018-02-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA12776207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine