Provider Demographics
NPI:1225252810
Name:JACOBS, KENNETH ALLEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7517 DANBURY DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3564
Mailing Address - Country:US
Mailing Address - Phone:248-895-0216
Mailing Address - Fax:
Practice Address - Street 1:18500 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2319
Practice Address - Country:US
Practice Address - Phone:313-272-5256
Practice Address - Fax:313-272-9780
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302024203OtherPHARMACY LICENSE NUMBER