Provider Demographics
NPI:1669140125
Name:MBA, JACOB N
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:N
Last Name:MBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4257 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-1926
Mailing Address - Country:US
Mailing Address - Phone:405-215-0521
Mailing Address - Fax:
Practice Address - Street 1:4257 58TH AVE
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-1926
Practice Address - Country:US
Practice Address - Phone:405-215-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCNA0000812684Medicaid