Provider Demographics
NPI:1184675209
Name:JACOBELLI, MICHAEL C
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:JACOBELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 LANGHORNE NEWTOWN RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-1219
Mailing Address - Country:US
Mailing Address - Phone:215-757-5131
Mailing Address - Fax:215-757-5870
Practice Address - Street 1:1205 LANGHORNE NEWTOWN RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1219
Practice Address - Country:US
Practice Address - Phone:215-757-5131
Practice Address - Fax:215-757-5870
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024059E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009647870003Medicaid
PA123384Medicare ID - Type Unspecified
PA0009647870003Medicaid