Provider Demographics
NPI:1568084507
Name:NASSER, JACOB (DPM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:NASSER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:
Practice Address - Street 1:226 MEDICAL PLAZA LN
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7425
Practice Address - Country:US
Practice Address - Phone:606-633-4871
Practice Address - Fax:606-633-4300
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY291460213ES0103X
NYP122264390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP122264Medicaid