Provider Demographics
NPI:1760881346
Name:JACOBS, DANA MARIE (ATC, SCAT)
Entity Type:Individual
Prefix:MISS
First Name:DANA
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3971 LEWISVILLE HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:RICHBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29729-9029
Mailing Address - Country:US
Mailing Address - Phone:803-789-1094
Mailing Address - Fax:
Practice Address - Street 1:3971 LEWISVILLE HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:RICHBURG
Practice Address - State:SC
Practice Address - Zip Code:29729-9029
Practice Address - Country:US
Practice Address - Phone:803-789-1094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer