Provider Demographics
NPI:1558619940
Name:JACOBS, AMANDA KRISTEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:KRISTEN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 HOFFMEISTER DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7045
Mailing Address - Country:US
Mailing Address - Phone:704-989-7751
Mailing Address - Fax:
Practice Address - Street 1:2707 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9406
Practice Address - Country:US
Practice Address - Phone:803-366-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13747183500000X
NC22849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist