Provider Demographics
NPI:1740594308
Name:JACOBS, MARINEL (PT)
Entity Type:Individual
Prefix:
First Name:MARINEL
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14605 POTOMAC BRANCH DR
Mailing Address - Street 2:SUITE #300
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3336
Mailing Address - Country:US
Mailing Address - Phone:703-490-1330
Mailing Address - Fax:703-878-8735
Practice Address - Street 1:14605 POTOMAC BRANCH DR
Practice Address - Street 2:SUITE #300
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3336
Practice Address - Country:US
Practice Address - Phone:703-490-1330
Practice Address - Fax:703-878-8735
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist