Provider Demographics
NPI:1730369018
Name:JACOBS, GREGORY D (PA-C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
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 1:1454 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-4944
Mailing Address - Country:US
Mailing Address - Phone:903-297-1733
Mailing Address - Fax:903-295-1600
Practice Address - Street 1:3100 23RD ST STE T
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-3161
Practice Address - Country:US
Practice Address - Phone:402-564-2816
Practice Address - Fax:402-564-1312
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K3359Medicare PIN