Provider Demographics
NPI:1588838585
Name:JACOBS, DIANNE ROSEBERRY (PAC)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:ROSEBERRY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:R
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:1699 LEADENHALL STREET
Mailing Address - Street 2:SPRING GARDENS MEDICAL DISPENSARY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230
Mailing Address - Country:US
Mailing Address - Phone:410-291-4800
Mailing Address - Fax:410-291-4511
Practice Address - Street 1:1699 LEADENHALL STREET
Practice Address - Street 2:SPRING GARDENS MEDICAL DISPENSARY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230
Practice Address - Country:US
Practice Address - Phone:410-291-4800
Practice Address - Fax:410-291-4511
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical