Provider Demographics
NPI:1306126032
Name:JACOB, MARK (FNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13737 NOEL RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-1331
Practice Address - Country:US
Practice Address - Phone:214-712-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily