Provider Demographics
NPI:1548667264
Name:JACOBS, MATT B (PA-C)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:B
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 E. EAGLE DRIVE #20730
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-3031
Mailing Address - Country:US
Mailing Address - Phone:480-706-9430
Mailing Address - Fax:480-378-2273
Practice Address - Street 1:5155 E. EAGLE DRIVE #20730
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85277-3031
Practice Address - Country:US
Practice Address - Phone:480-706-9430
Practice Address - Fax:480-378-2273
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ981219Medicaid
AZP01499301OtherRAILROAD MEDICARE
AZZ172754Medicare PIN