Provider Demographics
NPI:1558045542
Name:JACOBS, TYRONE RONNELL SR
Entity Type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:RONNELL
Last Name:JACOBS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 CORNWALL DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-1132
Mailing Address - Country:US
Mailing Address - Phone:540-684-4597
Mailing Address - Fax:
Practice Address - Street 1:436 CORNWALL DR
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-1132
Practice Address - Country:US
Practice Address - Phone:540-684-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63427396343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)