Individual
DR. DIANA R JACOBS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
13111 N PORT WASHINGTON RD, MEQUON, WI 53097-2416
(262) 243-6548
(262) 243-7599
Mailing address
4425 N PORT WASHINGTON RD, ATTN: CLINIC CREDENTIALING, GLENDALE, WI 53212-1082
(414) 963-7100
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
27996
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30045000
—
WI
Enumeration date
09/25/2006
Last updated
07/21/2022
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