CLYDE TYRONE JACOB III MD Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****68

License Status

NOT RENEWED

Business

First Name

CLYDE

Middle

TYRONE

Last Name

JACOB

Suffix

III MD

Business Name

CLYDE TYRONE JACOB III MD

Original Issue Date

06/30/1998

Effective Date

06/30/1998

Expiration Date

07/31/2002

City

BLOOMINGTON

State

Zip

61704

County

MCLEAN

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/09/2006