Provider Demographics
NPI:1346242112
Name:JACOBUS, KELLY TODD (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:TODD
Last Name:JACOBUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-6773
Mailing Address - Country:US
Mailing Address - Phone:336-249-3329
Mailing Address - Fax:336-249-3795
Practice Address - Street 1:102 W MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6773
Practice Address - Country:US
Practice Address - Phone:336-249-3329
Practice Address - Fax:336-249-3795
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22723Medicare UPIN
NCNC3334AMedicare PIN
Q22723Medicare UPIN