Provider Demographics
NPI:1003417585
Name:JACOBS, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
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 1:100 MONDAMIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8216
Mailing Address - Country:US
Mailing Address - Phone:803-479-7696
Mailing Address - Fax:
Practice Address - Street 1:100 MONDAMIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8216
Practice Address - Country:US
Practice Address - Phone:803-479-7696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X, 261QH0100X
SC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service