Provider Demographics
NPI:1073715686
Name:JACOB, JEFFREY T (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29275 NORTHWESTERN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5700
Mailing Address - Country:US
Mailing Address - Phone:248-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:3555 W 13 MILE RD STE N220
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-784-3667
Practice Address - Fax:248-869-3982
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4301108040207T00000X
MN50861207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIENROLLEDMedicaid
MNP01152444OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
MNENROLLEDMedicaid
WIENROLLEDMedicaid
IAENROLLEDMedicaid