Provider Demographics
NPI:1124386495
Name:JACOBS MEDICAL SUPPLY,LLC
Entity Type:Organization
Organization Name:JACOBS MEDICAL SUPPLY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:VALERA
Authorized Official - Last Name:NERIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-647-4193
Mailing Address - Street 1:8213 CRICHTON WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-8028
Mailing Address - Country:US
Mailing Address - Phone:916-647-4193
Mailing Address - Fax:916-896-5115
Practice Address - Street 1:8213 CRICHTON WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8028
Practice Address - Country:US
Practice Address - Phone:916-647-4193
Practice Address - Fax:916-896-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201013710108332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies