Provider Demographics
NPI:1487016465
Name:JACOBS, EMILY ALYSON (DO)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ALYSON
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FRANKLIN HEALTH CMNS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6144
Mailing Address - Country:US
Mailing Address - Phone:207-778-0482
Mailing Address - Fax:207-778-0133
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2893204D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM