Provider Demographics
NPI:1528569654
Name:JACOBS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
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 1:111 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:NOCONA
Mailing Address - State:TX
Mailing Address - Zip Code:76255-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 JACKSON ST
Practice Address - Street 2:
Practice Address - City:NOCONA
Practice Address - State:TX
Practice Address - Zip Code:76255-1014
Practice Address - Country:US
Practice Address - Phone:940-232-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335576164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse