Provider Demographics
NPI:1831118611
Name:JACOBS, MARIANNE BERNADETTE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:BERNADETTE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:615-345-5405
Practice Address - Street 1:3109 SILKWOOD LN
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33953-5686
Practice Address - Country:US
Practice Address - Phone:615-345-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO316152084N0400X, 2084P2900X, 2084S0012X
FLOS53462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01316157Medicaid
84132889816OtherSECURE HORIZONS
CT50813OtherSTATE LICENSE
FL57444YOtherMEDICARE PTAN
841328898011OtherROCKY MOUNTAIN HEALTH PLA
FLP01290076OtherRAILROAD MEDICARE
FL57444YOtherMEDICARE PTAN
COE52605Medicare UPIN
P00457365Medicare PIN
841328898011OtherROCKY MOUNTAIN HEALTH PLA