Provider Demographics
NPI:1558147157
Name:JACOBS, CAMILLE OLIVIA
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:OLIVIA
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 1:4186 N COLGATE CIR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1736
Mailing Address - Country:US
Mailing Address - Phone:414-627-5638
Mailing Address - Fax:
Practice Address - Street 1:4186 N COLGATE CIR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1736
Practice Address - Country:US
Practice Address - Phone:414-627-5638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management