Provider Demographics
NPI:1710271333
Name:FORT PIERCE FAMILY CARE, INC.
Entity Type:Organization
Organization Name:FORT PIERCE FAMILY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-661-8151
Mailing Address - Street 1:3709 OAK RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3706
Mailing Address - Country:US
Mailing Address - Phone:954-661-8151
Mailing Address - Fax:
Practice Address - Street 1:3851 VIRGINIA AVENUE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981
Practice Address - Country:US
Practice Address - Phone:954-661-8151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059609261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care