Provider Demographics
NPI:1174737639
Name:GEORGE I JACOB CHIROPRACTIC, INC
Entity type:Organization
Organization Name:GEORGE I JACOB CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-595-5711
Mailing Address - Street 1:PO BOX 578700
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8700
Mailing Address - Country:US
Mailing Address - Phone:209-595-5711
Mailing Address - Fax:
Practice Address - Street 1:3516 OAKDALE RD
Practice Address - Street 2:SUITE C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357-0727
Practice Address - Country:US
Practice Address - Phone:209-595-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4532436Medicaid
CADC27611OtherSTATE LICENSE
CA4532436Medicaid