Provider Demographics
NPI:1982027074
Name:JACOBS, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SE MENDAVIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5378
Mailing Address - Country:US
Mailing Address - Phone:772-634-8826
Mailing Address - Fax:
Practice Address - Street 1:3501 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5059
Practice Address - Country:US
Practice Address - Phone:772-288-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5197591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse