Provider Demographics
NPI:1326419821
Name:JACOB, JERILYN (RPH)
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:
Last Name:JACOB
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 1:6501 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6819
Mailing Address - Country:US
Mailing Address - Phone:410-938-3430
Mailing Address - Fax:
Practice Address - Street 1:6501 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6819
Practice Address - Country:US
Practice Address - Phone:410-938-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-10
Last Update Date:2015-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist