Individual
DR. KENNETH MICHAEL JACOB
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
19460 CALADESI DR, FORT MYERS, FL 33967-5572
(913) 707-0826
Mailing address
19460 CALADESI DR, APT/SUITE, FORT MYERS, FL 33967-5572
(913) 707-0826
(417) 772-7019
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
R3D70
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100154570D
—
KS
01
—
12485021
BCBS
—
05
—
203728035
—
MO
Enumeration date
02/01/2006
Last updated
11/13/2013
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