Provider Demographics
NPI:1073889416
Name:JACOBS, MAVIS (RN)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18811 SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3008
Mailing Address - Country:US
Mailing Address - Phone:646-523-3801
Mailing Address - Fax:
Practice Address - Street 1:8055 CORNISH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3728
Practice Address - Country:US
Practice Address - Phone:718-899-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY528003-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice