Provider Demographics
NPI:1689746844
Name:JACOBS, MARC LOUIS (DC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:LOUIS
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 1:2270 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3163
Mailing Address - Country:US
Mailing Address - Phone:516-379-0000
Mailing Address - Fax:516-379-7919
Practice Address - Street 1:2270 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3163
Practice Address - Country:US
Practice Address - Phone:516-379-0000
Practice Address - Fax:516-379-7919
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009276111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU74846Medicare UPIN