Provider Demographics
NPI:1962594929
Name:JACOBS, KRISTEN (MD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:JACOBS
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 1:3355 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1779
Mailing Address - Country:US
Mailing Address - Phone:574-234-4176
Mailing Address - Fax:574-234-1561
Practice Address - Street 1:3355 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1779
Practice Address - Country:US
Practice Address - Phone:574-234-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055183207ZP0102X
IN01037063207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND94739Medicare UPIN
IN738980HMedicare ID - Type Unspecified