Provider Demographics
NPI:1154301133
Name:JACOBY, SUSAN (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JACOBY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FRANKLIN HEALTH COMMONS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6144
Mailing Address - Country:US
Mailing Address - Phone:207-778-6394
Mailing Address - Fax:207-778-2886
Practice Address - Street 1:181 FRANKLIN HEALTH COMMONS
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6144
Practice Address - Country:US
Practice Address - Phone:207-778-6394
Practice Address - Fax:207-778-2886
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME50674363L00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES23324Medicare UPIN