Provider Demographics
NPI:1134143340
Name:JACOBUS, BRIAN BERNARD (DDS, MS, PA)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:BERNARD
Last Name:JACOBUS
Suffix:
Gender:M
Credentials:DDS, MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SW SAINT LUCIE WEST BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1735
Mailing Address - Country:US
Mailing Address - Phone:772-340-0023
Mailing Address - Fax:772-340-0840
Practice Address - Street 1:1100 SW SAINT LUCIE WEST BLVD STE 207
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1735
Practice Address - Country:US
Practice Address - Phone:772-340-0023
Practice Address - Fax:772-340-0840
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN103141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics