Provider Demographics
NPI:1902127756
Name:FORKE, JACOB PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:PAUL
Last Name:FORKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-3020
Mailing Address - Country:US
Mailing Address - Phone:406-535-6545
Mailing Address - Fax:
Practice Address - Street 1:406 1ST AVE S
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-3020
Practice Address - Country:US
Practice Address - Phone:406-535-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1902127756Medicaid
MT924810OtherBLUE CROSS BLUE SHIELD