Provider Demographics
NPI:1568679876
Name:JACOBS, DERIC L (DC)
Entity Type:Individual
Prefix:
First Name:DERIC
Middle Name:L
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4225
Mailing Address - Country:US
Mailing Address - Phone:386-562-4099
Mailing Address - Fax:
Practice Address - Street 1:4536 S. CLYDE MORRIS BLVD.
Practice Address - Street 2:SUITE 3
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4017
Practice Address - Country:US
Practice Address - Phone:386-562-4099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80054Medicare UPIN