Provider Demographics
NPI:1205438793
Name:JACOBS, RENITA D
Entity type:Individual
Prefix:
First Name:RENITA
Middle Name:D
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 1:8764 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-9147
Mailing Address - Country:US
Mailing Address - Phone:270-348-2734
Mailing Address - Fax:
Practice Address - Street 1:120 SAM WALTON DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-9311
Practice Address - Country:US
Practice Address - Phone:270-726-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist