Provider Demographics
NPI:1821522632
Name:JACOBS, MARISSA (DO)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19389 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6500
Mailing Address - Country:US
Mailing Address - Phone:623-537-6000
Mailing Address - Fax:623-537-6014
Practice Address - Street 1:19389 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6500
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:623-537-6014
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine