Individual
MR. MICHAEL BLAKE JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2855 CAMPUS DR, PLYMOUTH, MN 55441-2649
(763) 577-7000
Mailing address
5600 CAMERATA WAY UNIT 221, ST LOUIS PARK, MN 55416-5285
(612) 590-3809
Taxonomy
Speciality
Code
Description
License number
State
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
12595
MN
363A00000X
Physician Assistant
Primary
12593
MN
Other
Enumeration date
11/22/2017
Last updated
03/11/2021
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