Provider Demographics
NPI:1912369992
Name:JACOBS, GENEVIEVE CAMILLA (DO)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:CAMILLA
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04488207R00000X, 208100000X
KYR4099207R00000X
MT131835208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine