Provider Demographics
NPI:1508951872
Name:JACOB, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1430
Mailing Address - Country:US
Mailing Address - Phone:317-936-3970
Mailing Address - Fax:317-943-9989
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1430
Practice Address - Country:US
Practice Address - Phone:317-936-3970
Practice Address - Fax:317-943-9989
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200270340Medicaid
IN200270340Medicaid
IN151560H3Medicare PIN
IN151560H3Medicare PIN
IN200270340Medicaid