Provider Demographics
NPI:1427205996
Name:JACOBS, JOHN A (RD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:JACOBS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR
Practice Address - Street 2:SUITE 202
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8301
Practice Address - Country:US
Practice Address - Phone:607-795-2820
Practice Address - Fax:607-795-2821
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000610-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103046786Medicaid
NY03576318Medicaid
PA103046786Medicaid