Provider Demographics
NPI:1033508791
Name:JACOBS CLINIC, INC.
Entity Type:Organization
Organization Name:JACOBS CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:912-816-8956
Mailing Address - Street 1:403 LISTER ST
Mailing Address - Street 2:A
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5225
Mailing Address - Country:US
Mailing Address - Phone:912-816-8956
Mailing Address - Fax:
Practice Address - Street 1:403 LISTER ST
Practice Address - Street 2:A
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5225
Practice Address - Country:US
Practice Address - Phone:912-816-8956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN121991NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP35295Medicare UPIN