Provider Demographics
NPI:1154019156
Name:JACOB, JUDY JOMON (PA)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:JOMON
Last Name:JACOB
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12377 MERIT DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-3126
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3844
Practice Address - Country:US
Practice Address - Phone:940-626-2110
Practice Address - Fax:940-626-2113
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant