Provider Demographics
NPI:1275949679
Name:JACOBS, HENRIETTA ANNE (RPH)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:ANNE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 S SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6964
Mailing Address - Country:US
Mailing Address - Phone:505-992-8638
Mailing Address - Fax:
Practice Address - Street 1:3001 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6964
Practice Address - Country:US
Practice Address - Phone:505-992-8638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist