Provider Demographics
NPI:1093989006
Name:JON R JACOBS
Entity Type:Organization
Organization Name:JON R JACOBS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:843-797-6564
Mailing Address - Street 1:9213 UNIVERSITY BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9145
Mailing Address - Country:US
Mailing Address - Phone:843-797-6564
Mailing Address - Fax:843-572-9165
Practice Address - Street 1:9213 UNIVERSITY BLVD STE D
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9145
Practice Address - Country:US
Practice Address - Phone:843-797-6564
Practice Address - Fax:843-572-9165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC199702336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC611963397OtherMEDICARE
SC1568535953OtherNPI- SINGLE PROVIDER
SC113004Medicaid
SCC61196Medicare UPIN