Provider Demographics
NPI:1003157173
Name:JACOBS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 289TH ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43611-2908
Mailing Address - Country:US
Mailing Address - Phone:419-276-0147
Mailing Address - Fax:
Practice Address - Street 1:4309 289TH ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43611-2908
Practice Address - Country:US
Practice Address - Phone:419-276-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN152353164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse