Provider Demographics
NPI:1508231606
Name:JACOBS, DURELL (IDC)
Entity Type:Individual
Prefix:
First Name:DURELL
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE BLDG 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5291
Mailing Address - Country:US
Mailing Address - Phone:619-532-7968
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5291
Practice Address - Country:US
Practice Address - Phone:619-532-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710L1002X-1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman