Provider Demographics
NPI:1275973612
Name:JACOBS, DESHA PERRY (RN, CDE)
Entity Type:Individual
Prefix:
First Name:DESHA
Middle Name:PERRY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 SAGES AVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-6621
Mailing Address - Country:US
Mailing Address - Phone:704-493-2087
Mailing Address - Fax:
Practice Address - Street 1:4505 SAGES AVE
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-6621
Practice Address - Country:US
Practice Address - Phone:704-493-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-30
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164318174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2092-0582OtherNATIONAL CERTIFICATION BOARD FOR DIABETIC EDUCATORS