Provider Demographics
NPI:1891779385
Name:JAKUBIAK, AMIE MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:MICHELLE
Last Name:JAKUBIAK
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1025 VERDAE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-286-7550
Practice Address - Fax:864-286-7551
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015339207Q00000X
SC36179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC361798Medicaid
SCSC18677951Medicare PIN
SC361798Medicaid