Provider Demographics
NPI:1235883976
Name:JACOBS, REGINA LYNNE (RDH)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:LYNNE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12920 LEATHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8301
Mailing Address - Country:US
Mailing Address - Phone:571-263-6677
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP RM O1.301B
Practice Address - Street 2:
Practice Address - City:FT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:571-263-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402205621124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist