Provider Demographics
NPI:1174671804
Name:JACOBS, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CANDIA RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03109-5512
Mailing Address - Country:US
Mailing Address - Phone:603-627-5539
Mailing Address - Fax:603-627-5539
Practice Address - Street 1:1600 CANDIA RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03109-5512
Practice Address - Country:US
Practice Address - Phone:603-627-5539
Practice Address - Fax:603-627-5539
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH85582084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE1920Medicare ID - Type Unspecified
NHF08218Medicare UPIN