Provider Demographics
NPI:1629203468
Name:JACOBS, MICHAELA HANEY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:HANEY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4545 ALAMEDA BLVD NE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1591
Mailing Address - Country:US
Mailing Address - Phone:505-896-2900
Mailing Address - Fax:505-938-4198
Practice Address - Street 1:4545 ALAMEDA BLVD NE
Practice Address - Street 2:SUITE G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1591
Practice Address - Country:US
Practice Address - Phone:505-896-2900
Practice Address - Fax:505-938-4198
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0154207ZD0900X
NMMD20130154207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology