Provider Demographics
NPI:1205433653
Name:JACOBS, ANTHONY L I
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:JACOBS
Suffix:I
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 1:15504 ROWENA AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-4828
Mailing Address - Country:US
Mailing Address - Phone:216-905-1606
Mailing Address - Fax:
Practice Address - Street 1:15504 ROWENA AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-4828
Practice Address - Country:US
Practice Address - Phone:216-905-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide