Provider Demographics
NPI:1902210404
Name:JACOBS, BRYAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:850-881-5222
Mailing Address - Fax:850-881-3123
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-5222
Practice Address - Fax:850-881-3123
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics