Provider Demographics
NPI:1508461377
Name:JACOBS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 S GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-8717
Mailing Address - Country:US
Mailing Address - Phone:612-708-5231
Mailing Address - Fax:
Practice Address - Street 1:350 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6392
Practice Address - Country:US
Practice Address - Phone:563-589-2472
Practice Address - Fax:563-589-2616
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA214131835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care