Provider Demographics
NPI:1073938130
Name:JACOBS, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
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 1:200 SAINT CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3913
Mailing Address - Country:US
Mailing Address - Phone:912-439-0207
Mailing Address - Fax:
Practice Address - Street 1:200 SAINT CHARLES PL
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3913
Practice Address - Country:US
Practice Address - Phone:912-439-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health